The role of routine abdominal drainage after bariatric surgery: a metabolic and bariatric surgery accreditation and quality improvement program study

Trends of Drain Placement During Revisional Bariatric Surgeries and Its Association with 30-Day Morbidity: An MBSAQIP Analysis of 64,495 Patients

Background: Drains are often placed during bariatric procedures; however, their use in conversional or revisional bariatric surgery (CRBS) has not been thoroughly explored. Our study sought to identify the frequency of drain placement in CRBS, and characterize factors associated with drain placement and their influence on 30-day serious complications. Methods: Patients undergoing CRBS between 2020 and 2022 were included from the MBSAQIP database. Patients were placed into drain placed (DP) versus no drain (ND) cohorts and baseline characteristics and complication rate were compared. Multivariable logistic regression models were used to identify independent predictors of drain placement and complications. Results: of 64,495 included patients, drains were placed in 19.1% in 2020; this was down to 14.4% in 2022. Drain placement was associated with increased risk of multiple complications such as hemorrhage, readmission, surgical site infection, and gastrointestinal bleeding. On multivariate analysis, drain placement was an independent predictor of serious complications (aOR 1.45, p < 0.001), anastomotic leak (aOR 2.25, p < 0.001), organ space infection (aOR 2.12, p < 0.001), and reoperation (aOR 1.37, p < 0.001), as well as excess LOS (aOR 2.06, p < 0.001). Predictors of drain placement include older age, higher BMI, smoking status, history of venous thromboembolism, and procedural factors, such as undergoing non-sleeve revisional surgery or having an intraoperative leak test. Conclusions: Drain placement during CRBS surgical procedures is common and more likely in higher risk patients and anastomotic revisional procedures. Though the reasons for drain placement were not available, these data suggest that surgeons should be judicious in selecting patients for drain placement due to its association with increased LOS and postoperative morbidity in CRBS.

Effectiveness of a Nurse-Led Telecare Programme in the Postoperative Follow-Up of Bariatric Surgery Patients: A Quasi-Experimental Study

BACKGROUND/OBJECTIVES

Obesity is a growing public health challenge due to its high prevalence and associated comorbidities. Bariatric surgery is the most effective treatment for achieving sustained weight reduction when more conservative treatments have failed. This study evaluates the impact of a nurse-led telecare follow-up programme in the immediate postoperative period for patients who have undergone bariatric surgery.

METHODS

A quasi-experimental study was carried out in two hospitals in southern Spain. We included 161 patients who met the inclusion criteria: a body mass index (BMI) ≥ 40 kg/m2 or a BMI ≥ 35 kg/m2 with associated comorbidities, and the failure of non-surgical treatments. Patients were divided into two groups: the intervention group (IG), which received follow-up telephone calls from a specialised nurse during the first 30 days post-surgery, and the control group (CG), which received standard care. The nurse, who was available 24 h a day, answered questions and dealt with queries over the phone or referred patients to the emergency department if necessary. Several variables were recorded, including the number of telephone consultations, reasons for consultation, number of emergency visits, readmissions, and surgical reinterventions.

RESULTS AND CONCLUSIONS

The IG showed a significant reduction in ED visits (4.9% vs. 30% in CG), and consultations were mainly related to diet and drainage. The nurse telecare intervention significantly improved postoperative recovery by reducing complications and optimising the safety and quality of postoperative care. These results reinforce the importance of personalised follow-up in improving clinical outcomes in bariatric patients.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU).

METHODS

PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee.

RESULTS

Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Abdominal Drains After Laparoscopic Sleeve Gastrectomy: Should They Be Used?

Purpose

Laparoscopic sleeve gastrectomy (LSG) is one of the most common surgical procedures worldwide for the treatment of morbid obesity. Blake-type drains are widely used in this procedure despite the lack of clear evidence regarding their benefits in the diagnosis and treatment of common postoperative complications such as gastric suture line leak (GSLL) and postoperative bleeding (PB).

Materials and Methods

A retrospective descriptive study with prospective case registry was conducted, analyzing all patients who underwent LSG between January 2012 and December 2022 at a high-volume center. Our primary outcome was to evaluate the role of drains for diagnosis and treatment of GSLL and PB in LSG. Our secondary outcome was to determine drain related surgical site infection (DRSSI) rate.

Results

A total of 335 LSG were performed in the studied period. In all patients one abdominal drain was placed during surgery. Six GSLL (1.79%) and 5 PB (1.49%) were recorded. Drain placement did not prove to ensure early diagnosis or conservative management of GSLL or PB after LSG. Furthermore, an incidence of DRSSI of 4.1% (14 patients) was found.

Conclusion

In our study, no clear diagnostic or therapeutic benefits of the systematic use of drains for GSLL or PB in LSG was found; but drain use did show a considerable rate of DRSSI, which must be taken into consideration prior to considering drain systematic use. While no randomized prospective trials have been performed, the retrospective data does not support drain systematic use.

The Impact of Drain Placement on Postoperative Complications in Bariatric Surgery: A Systematic Review and Meta-Analysis

Obesity in individuals can have consequences ranging from metabolically healthy obesity to serious morbidities and reduce the quality and duration of life. A meta-analysis was conducted to assess the role of abdominal drainage on postoperative complications after bariatric surgery. PubMed, Embase, and the Cochrane Library were systematically searched for eligible studies. The results revealed that abdominal drainage was associated with surgical complications, with a pooled odds ratio (OR) of 1.70 (P < .001), but not associated with wound infection (OR: 1.04; P = .762). Associations with surgical complications were mainly detected from retrospective cohort studies. The use of abdominal drainage showed associations with death (OR: 1.68; P < .001) and reoperation (OR: 1.49; P < .001). These findings revealed that abdominal drainage during bariatric surgery was associated with surgical complications, death, and reoperation. These results should be taken with caution since randomized controlled trials and retrospective studies were analyzed together.

Risk Factors for Readmission After Same-Day Discharge Sleeve Gastrectomy: a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database Analysis

Background

Same-day discharge after sleeve gastrectomy (SG) is gaining popularity. We aimed to determine risk factors associated with readmission in patients who underwent same-day discharge SG.

Methods

We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for the period 2015–2018. Patients who underwent SG and were discharged the same day of the operation were included in the analysis. Multivariable logistic regression analysis was performed to determine risk factors for readmission.

Results

A total of 466,270 SG were performed during the study period; 14,624 (3.1%) patients were discharged the same day and were included in the analysis. Mean age was 43.4 (14.7–80) years and 11,718 (80.1%) were female. Mean preoperative BMI was 43.7 ± 7.4 kg/m². Mean operative time was 58.3 ± 32.4 min. Thirty-day reoperation, reintervention, and mortality rates were 0.7%, 0.7%, and 0.1%, respectively. Readmission rates were similar in same-day discharge and inpatient SG (2.9% vs. 3%, p = 0.5). Female sex (OR 1.52, 95% CI 1.15–2.00), preoperative gastroesophageal reflux disease (OR 1.33, 95% CI 1.08–1.64), renal insufficiency (OR 3.06, 95% CI 1.01–9.32), and intraoperative drain placement (OR 1.78, 95% CI 1.37–2.31) were independent risk factors for readmission following same-day discharge SG.

Conclusions

Same-day discharge SG appears to be safe and is associated with low readmission rates. However, the identification of preoperative and intraoperative variables associated with higher risk of readmission might help defining safer and more effective same-day discharge protocols.

Graphical abstract

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

The Impact of Drain and Reinforcement on the Outcomes of Bariatric Surgery: A Prospective Study

Purpose We aimed to investigate the impact of reinforcement and abdominal drains on the outcome of laparoscopic sleeve gastrectomy (LSG). Methods The present study was a prospective study that included obese patients scheduled to undergo LSG. Patients were assigned to receive drain, reinforcement, or both according to the surgeon's preference and followed up for one month after surgery. The present study's primary outcome was the identification of the association between intraoperative drain/reinforcement and the incidence of postoperative complications. Results A total of 125 (20.3%) patients received intraoperative drains. The proportion of postoperative morbidity was comparable between the drain and non-drain groups (3.2% versus 1.6%; p = 0.25). Patients in the drain group had similar incidence of blood transfusion (2.4% versus 1.7% in non-drain group; p = 0.43) and postoperative leakage (0.8% versus 0.2% in non-drain group; p = 0.36). The incidences of blood transfusion (p = 0.56) and reoperation (p = 0.98) were comparable between the drain and non-drain groups. There were no statistically significant differences between the drain and non-drain groups regarding postoperative mortality and wound infection (p > 0.05). On the other hand, 440 (71.3%) patients received reinforcement. The proportion of postoperative morbidity was comparable between the reinforcement and non-reinforcement groups (1.6% versus 2.8%, p = 0.07). Patients in the reinforcement group were less likely to develop postoperative bleeding (0.7% versus 4% in the non-reinforcement group; p = 0.004), while no significant difference was detected in terms of postoperative leakage (p = 0.33) and in-hospital mortality. Conclusion In conclusion, abdominal drainage did not reduce the complications of LSG patients. Reinforcement has some role in controlling the bleeding but not leaks. Both techniques did not significantly impact the mortality rate. In the future, additional, large randomized trials are needed to examine the gastrointestinal-related quality of life.

Infection prevention plan to decrease surgical site infections in bariatric surgery patients

BACKGROUND

Surgical site infections (SSI) are one of the most common complications of bariatric surgery. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (QI) Program (MBSAQIP) allows accredited programs to develop processes for quality improvement based on data collection. The objective of this study was to decrease SSI rates in patients undergoing bariatric surgery at an accredited MBSAQIP center.

METHODS

Using the MBSAQIP semiannual report, SSI rates were retrospectively reviewed. Baseline SSI rates were collected from 01/01/2014-12/31/2015. On 01/01/2016, the first infection prevention protocol (IPP-1) was created that included 4% chlorhexidine gluconate (CHG) showers, CHG wipes immediately prior to surgery, and routine cultures of SSIs. An updated IPP (IPP-2) was implemented on 09/01/2016, which discontinued routine surgical drain placement and broadened antibiotic coverage for penicillin allergic patients.

RESULTS

During baseline data collection, SSI rates were 5.1%. After the implementation of IPP-1, SSI rates trended down to 2.5%. After implementation of IPP-2, SSI rates decreased significantly to 1.5%, a 66% relative risk reduction in SSIs from baseline. On multivariate regression analysis, the perioperative factors associated with an increased risk for SSIs included diabetes mellitus, intraoperative surgical drain placement, the number of hypertension medications prior to bariatric surgery, and an open approach.

CONCLUSIONS

Our study demonstrates that the implementation of a specific protocol for reducing SSIs is safe and feasible in patients undergoing bariatric surgery. We also identified that the success of the IPP is likely centered on the elimination of routine drain placement during primary bariatric procedures.

Drain Placement During Bariatric Surgery, Helpful or Harmful?

INTRODUCTION

Routine drain placement is still widely used in both sleeve gastrectomy (SG) and Roux en Y gastric bypass (REYGB). There is mounting evidence that drains may increase complication risk without preventing reoperation or other complications.

METHODS

Data from 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File was evaluated for drain use during laparoscopic REYGB and SG. Primary outcomes were superficial and deep surgical site infections (SSI), reintervention/reoperation, and readmission. Preoperative patient risk factors were also compared to evaluate for association with drain placement.

RESULTS

A total of 148 260 patients fit the inclusion criteria. Drains were used in 23 190 (15.6%) cases and not used in 125 070 (84.4%). Drain placement during surgery was associated with increased odds of superficial SSI, deep incisional SSI, and organ space SSI. Patients with drains were found to have increased odds of requiring at least 1 reoperation or intervention within 30 days of surgery. Preoperative risk factors associated with drain placement included diabetes mellitus, a history of chronic obstructive pulmonary disease, and oxygen dependence. Smokers were slightly less likely to have a drain placed. There was no significant association with chronic steroid and immunosuppressant usage.

CONCLUSION

There is mounting data against drain placement during bariatric surgery. Prior studies using MBSAQIP data have shown an increased complication rate with drains, and our data set supports the idea that drains may increase complications after surgery. While no randomized prospective trials have been performed looking at drain usage in bariatric surgery, the growing retrospective data certainly inform against the regular use of drains.

Evolving Trends in North American Gastric Bypass Delivery: a Retrospective MBSAQIP Analysis of Technical Factors and Outcomes from 2015 to 2018

PURPOSE

A number of procedural and technical factors have been adopted over time to overcome the steep learning curve and adverse safety profile of Roux-en-Y gastric bypass (RYGB). However, the evolution and impact of these factors are not currently known which limits our ability to optimize RYGB delivery.

MATERIALS AND METHODS

Data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2018. All primary RYGB procedures were included while prior revisional surgeries and emergency surgeries were excluded. Primary outcomes included characterizing the trends in procedural and technical factors associated with RYGB.

RESULTS

A total of 156,941 patients underwent primary RYGB from 2015 to 2018 with a mean age of 45.2 ± 11.9 years and a mean body mass index of 46.4 ± 8.4 kg/m [1]. The majority of patients were female (80.3%), of white racial status (73.5%), and of non-smoking status (92.1%). The most commonly performed approach was laparoscopic RYGB although an increase in robotic cases was observed over time. Rates of drain placement and postoperative swallow studies decreased by 10% from 2015 to 2018. Together, these trends were associated with reductions in serious complications, readmission, and re-intervention rates over time.

CONCLUSION

The proportion of RYGB cases performed in MBSAQIP accredited centers has decreased from 2015 to 2018 associated with an increased adoption of sleeve gastrectomy Leaks, serious complications, readmission, and reintervention rates improved with each operative year suggesting that the technical proficiency and safety of RYGB continue to evolve with time.

Usefulness of Abdominal Drain in Laparoscopic Roux-en-Y Gastric Bypass: A Randomized Controlled Trial

Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is one of the most common procedures to treat morbid obesity. Abdominal drains are often placed during the operation to detect complications earlier. The aim of this study was to assess the benefit of routine drain placement during laparoscopic RYGB. Materials and Methods: A consecutive series of patients undergoing laparoscopic RYGB between 2017 and 2018 was analyzed. The sample was randomized before the procedure into two groups: with abdominal drain (G1) and without abdominal drain placement (G2). Patients with intraoperative complications were excluded from the randomization. Postoperative complications and pain (visual analogue scale) were compared between groups. Results: A total of 84 patients were included; 45 belonged to G1 and 39 to G2. Mean age (G1 44 years versus G2 48 years) and body mass index (G1 43 kg/m2 versus G2 44 kg/m2) were similar in both groups. There were no significant differences between groups in preoperative comorbidities. Mean operative time was 92 minutes in both groups. Mean pain score at postoperative day 0 was similar in both groups (G1 3.2 versus G2 3.5, P = .58), but was higher in G1 at postoperative day 1 (G1 3.1, G2 1.1, P = .02). Postoperative Clavien-Dindo I-II complications were similar in both groups (G1 9% versus G2 1%, P = .37). No major complications, reoperations, or 30-day mortality occurred in the entire cohort. Conclusions: Drain placement in laparoscopic RYGB was associated with greater postoperative pain and did not show benefits in early detection of postoperative complications. Routine placement of abdominal drain in laparoscopic RYGB might not be recommended.

[Still no evidence for drains in bariatric surgery]

BACKGROUND

Registry data show that placement of a drain during bariatric surgery is still the normal practice in many surgical departments. Retrospective studies and a review article could show that the routine placement of a drain in bariatric surgery is useless and also potentially dangerous. Due to the lack of randomized controlled studies there is insufficient evidence on this topic in the literature.

OBJECTIVE

In order to further question the use of drains in bariatric interventions, the prospective in-house databank of patients who received a gastric sleeve (SG) or a Roux-en‑Y gastric bypass (RYGB) between January 2010 and June 2016 was retrospectively evaluated.

SETTING

A German university hospital.

METHODS

During the investigation period a total of 361 operations (219 gastric bypasses and 142 gastric sleeve operations) were carried out. A change in the internal treatment pathway with respect to the placement of drains in 2013 led to the formation of two groups: one where a drain was routinely placed in operations (n = 166) and a second group where a drain was not routinely placed (n = 195). The demographic data were statistically adjusted between the two groups using multiple regression analysis. The results of the operation and the 30-day morbidity were compared. Complications were evaluated according to the Clavien-Dindo classification.

RESULTS

In the group with no drain, complications occurred in seven patients. In the group with drainage there were 6 complications. The insufficiency and reoperation rates were not statistically significantly different between the two groups. The average postoperative hospital stay was 1.3 days longer in patients with a drain. Multivariate analysis showed that the placement of a drain was the greatest risk factor for a longer hospital stay.

CONCLUSION

Placement of a drain during bariatric interventions should only be considered on an individual basis. The routine placement should be discouraged.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Trends in Drain Utilization in Bariatric Surgery: an Analysis of the MBSAQIP Database 2015-2017

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (SG) are the two most common bariatric operations. With the implementation of enhanced recovery protocols, the use of drains should decrease.

Methods

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was queried for the years 2015–2017. Our inclusion criteria included all patients undergoing a primary LRYGB, SG, and revisions. We examined demographics, operative characteristics, the use of drains, and postoperative complications. Continuous variables were summarized using means and standard deviations (SD). Categorical variables were summarized using frequencies and proportions. Student’s T test (Wilcoxon sum rank test in the case of skewed data) and chi-squared analysis were used to assess the baseline differences in drain utilization.

Results

From 2015 to 2017, there were 388,239 bariatric cases performed without drains and 100,221 performed with drains. Twenty-nine percent of LRYGB patients had a drain placed but only 16.7% of SG patients. The percentage of LRYGB that had a drain dropped from 33.1 to 24.6% during the study period and that of SG dropped from 20.3 to 13.6%. Patients that had drains placed were more likely to have a provocative test at the time of surgery (prevalence ratio (PR) 2.24) and to have a postoperative swallow study (PR 1.93).

Conclusions

Drains are still commonly used in bariatric patients. Over the study period, there was a decrease in the use of drains in both bypass and sleeve patients. Patients with a drain were more likely to have had a provocative test and a swallow study and have a higher rate of complications and mortality.

Electronic supplementary material

The online version of this article (10.1007/s11695-019-04215-6) contains supplementary material, which is available to authorized users.

Role of abdominal drainage in bariatric surgery: Report of six cases

BACKGROUND

Abdominal drainage allows for timely detection of hemorrhage, but it cannot prevent hemorrhage. Whether routine abdominal drainage is needed during bariatric procedures remains controversial. Few reports describe the role of abdominal drainage in the diagnosis and treatment of abdominal hemorrhage in bariatric surgery.

CASE SUMMARY

Six cases of hemorrhage after bariatric surgery were described, including three cases with and three without abdominal drainage during the first surgery. The hemorrhage in five of the six cases was controlled by conservative treatment. Abdominal hemorrhage was found through the drainage tube on the day of the operation in the three patients with abdominal drainage during the first surgery. Emergency treatment was initiated, and their conditions gradually stabilized within 48 h. No patients required a reoperation. Abdominal hemorrhage was found later in the patients without abdominal drainage. Although the hemorrhage was controlled by conservative treatment in two cases (1 and 2), reoperation and percutaneous drainage were performed for abdominal infection and pelvic hemorrhage. An obsolete encapsulated effusion that may require treatment in the future was left in the abdominal cavity of a patient (Case 1).

CONCLUSION

The possibility of controlling abdominal hemorrhage after bariatric/metabolic surgery by conservative treatment is high. When hemorrhage occurs, abdominal drainage can reduce the probability of reoperation by reducing the formation of blood clots behind the stomach.

Predictors and outcomes of leak after Roux-en-Y gastric bypass: an analysis of the MBSAQIP data registry

BACKGROUND

Gastrointestinal leak is one of the most severe postoperative complications after Roux-en-Y gastric bypass (RYGB), occurring in up to 2% of all patients. This has led to adoption of simpler procedures, such as sleeve gastrectomy, which have improved safety profiles but potentially less effective long-term metabolic outcomes. Yet, in contrast to sleeve gastrectomy, a paucity of modern literature exists regarding predictors of leak for RYGB.

OBJECTIVES

The purpose of this study was to examine gastrointestinal leak in patients undergoing RYGB using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.

METHODS

We identified all Metabolic and Bariatric Surgery Accreditation and Quality Improvement patients who underwent RYGB in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of leak in RYGB patients. Our secondary outcomes of interest include characterizing overall complication rates in RYGB patients. Univariate analysis of pre-, intra-, and postoperative variables was performed using Χ² tests for categoric data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model was then developed to determine predictive factors for development of leak.

SETTING

All centers belonging to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.

RESULTS

A total of 77,596 patients underwent RYGB from 2015 to 2016. The majority of patients were female (79.8%), white (75.9%), and underwent laparoscopic RYGB (89.7%). The mean age of patients was 45.2 years (standard deviation 11.9) with a mean body mass index of 46.3 kg/m² (standard deviation 8.17). Complication rates for RYGB were low with a mortality of .16% and a total complication rate of 7.5%. A total of 476 leaks were identified with an overall leak rate of .6% and a mortality of 1.5%. Leak was associated with a statistically significant increase in all complications as well as readmission, reoperation, and mortality rates at 30 days. Multivariable logistic regression analysis revealed the following statistically significant independent predictors of leak: body mass index, age, operative length, American Society of Anesthesiologists score >3, prior pulmonary embolus, and partially dependent functional status. Albumin was the only independent protective variable after adjusting for confounders and interactions.

CONCLUSION

Using the robust Metabolic and Bariatric Surgery Accreditation and Quality Improvement database, we found RYGB to be a safe procedure with low morbidity and mortality. The overall leak rate was .6% with leak significantly increasing all other complications, readmission, reoperation, and mortality rates at 30 days. Logistic regression identified prior pulmonary embolus and partially dependent functional status as the 2 largest predictors of leak while increased albumin was the only protective factor. Optimizing preoperative nutrition and strength in these patients through structured multidisciplinary programs may therefore have a role in the ongoing improvement of outcomes after RYGB.

Influence of Drain Placement on Postoperative Pain Following Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: Randomized Controlled Trial

BACKGROUND

There is currently no evidence to support the routine use of an abdominal drain following laparoscopic Roux-en-Y gastric bypass (RYGB). Our aim was to investigate drain use in laparoscopic RYGB and its effects on postoperative pain.

METHODS

Sixty-six patients were randomly divided into two groups as no-drain (n = 36) and with-drain (n = 30). Intraoperative (time, blood loss, complications) and postoperative outcomes (morbidities, pain scores, hospital stay) were compared.

RESULTS

Demographics of both groups were comparable. Three patients in the no-drain group required a drain (8.3%). Median visual analog scale scores for days 1-3 for with-drain and no-drain groups were 4.5 (2-9) vs. 3 (0-8) (p = 0.02), 3 (0-7) vs. 2 (0-7) (p = 0.10), and 2 (0-7) vs. 0 (0-4) (p = 0.0004), respectively. There was no difference between the groups in terms of complications and length of hospital stay.

CONCLUSION

Drain use increased the postoperative pain following laparoscopic RYGB. Drain placement following laparoscopic RYGB should be selective instead of a routine application.