Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Shifting paradigms: protocol implementation to reduce length of stay for bariatric surgery following the pandemic at a high volume bariatric center

BACKGROUND

With the Covid-19 pandemic reducing the capacity to perform elective bariatric surgical cases, a multidisciplinary approach to reducing length of stay has been essential to continue providing this service. In conjunction with the use of our local ERAS protocols, same day discharge (SDD) and early next day discharge (NDD) for bariatric surgery is becoming more of a reality.

OBJECTIVES

To evaluate the effectiveness of our new protocols targeted at reducing length of stay (LOS) for our bariatric surgery patients during the pandemic. Secondary outcomes included comparisons of readmission and complications compared to baseline data.

METHODS

The MBSAQIP data set was analyzed identifying patients who underwent laparoscopic roux-en- Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (SG) from April to November 2021. Mean LOS and complication rates including re-admission in this baseline group were documented. This was compared to a cohort who underwent the surgeries between December 2021 and February 2022 under our new protocols for early discharge.

RESULTS

195 patients underwent bariatric surgery in the baseline group and 87 patients in the early discharge cohort were included. There was a statistically significant decrease in mean LOS comparing baseline group (34.5 h) and next day PACU discharges (25 h) with P = 0.004. No increase in complication rate from the early discharge cohort against the baseline group. (P = 0.014).

CONCLUSION

SDD and NDD in carefully selected bariatric surgery patients is feasible with good outcomes. With ERAS protocols as a foundation and a multidisciplinary approach, this can be achieved in spite of pressures placed on bariatric units by the pandemic.

Comparative Safety and Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Weight Loss and Type 2 Diabetes Across Race and Ethnicity in the PCORnet Bariatric Study Cohort

Importance

Bariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups.

Objective

To compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study.

Design, Setting, and Participants

This was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022.

Exposure

RYGB or SG.

Outcomes

Percentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery.

Results

A total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, -7.6%; 95% CI, -8.0 to -7.1; P < .001; Hispanic, -6.2%; 95% CI, -6.6 to -5.9; P < .001; White, -5.9%; 95% CI, -6.3 to -5.7; P < .001; difference in change in year 5 HbA1c level: Black, -0.29; 95% CI, -0.51 to -0.08; P = .009; Hispanic, -0.45; 95% CI, -0.61 to -0.29; P < .001; and White, -0.25; 95% CI, -0.40 to -0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse.

Conclusions and Relevance

Variability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.

Association of Preoperative Glycosylated Hemoglobin Level with 30-Day Outcomes Following Laparoscopic Roux-en-Y Gastric Bypass: an Analysis of the ACS-MBSAQIP Database

PURPOSE

Elevated glycosylated hemoglobin (HbA₁c) levels have been associated with increased morbidity and mortality following several cardiac, colorectal, orthopedic, and vascular surgery operations. The purpose of this study was to determine if there is a HgA₁c cut-point that can be used in patients undergoing laparoscopic Roux-en-Y gastric bypass to decrease the risk of 30-day wound events and additional 30-day morbidity and mortality.

MATERIALS AND METHODS

All patients undergoing first-time, elective Roux-en-Y gastric bypass in 2017 and 2018 with a diagnosis of diabetes mellitus (DM) and a preoperative HbA₁c level were identified within the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative HbA₁c levels with 30-day morbidity and mortality was investigated.

RESULTS

A total of 13,806 patients met inclusion criteria. Two natural HbA₁c inflection points for composite wound events, including superficial, deep, and organ space surgical site infections (SSI) and wound dehiscence, were found. A HbA₁c level of ≤ 6.5% was associated with a decreased odds of experiencing the composite 30-day wound event outcome while a HbA₁c level of > 8.6% was associated with an increased odds of experiencing the composite 30-day wound event outcome. The differences in the incidence of the 30-day composite wound event outcomes were driven primarily by superficial and organ space SSI, including anastomotic leaks.

CONCLUSION

Patients with DM being evaluated for RYGB surgery with a HbA₁c level > 8.6% are at an increased risk for 30-day wound events, including superficial and organ space SSI.

Understanding the Bariatric Patient Perspective in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study

BACKGROUND

In 2016, the Patient-Centered Outcomes Research Institute funded the National Patient Centered Clinical Research Network (PCORnet) Bariatric Study (PBS). Understanding the experience of postoperative patients was a key component of this study.

METHODS

Nine focus groups were conducted in Southern California, Louisiana, Pennsylvania, and Ohio and in a national advocacy conference for patients with obesity. Participants were identified and recruited in both clinical and community settings. Focus group transcripts were analyzed using an iterative inductive-deductive approach to identify global overarching themes.

RESULTS

There were 76 focus group participants. Participants were mostly women (81.4%), had primarily undergone gastric sleeve (47.0%), were non-Hispanic white (51.4%), had some college education (44.3%), and made $100,000 annual income or less (65.7%). Qualitative findings included negative reactions patients received from friends, family, and co-workers once they disclosed that they had bariatric surgery to lose weight; and barriers to follow-up care included insurance coverage, emotional and situational challenges, and physical pain limiting mobility.

CONCLUSIONS

These findings confirm the other qualitative findings in this area. The approach to bariatric surgery should be expanded to provide long-term comprehensive care that includes in-depth postoperative lifetime monitoring of emotional and physical health.

Interventions and Operations 5 Years After Bariatric Surgery in a Cohort From the US National Patient-Centered Clinical Research Network Bariatric Study

Importance

Additional data comparing longer-term problems associated with various bariatric surgical procedures are needed for shared decision-making.

Objective

To compare the risks of intervention, operation, endoscopy, hospitalization, and mortality up to 5 years after 2 bariatric surgical procedures.

Design, Setting, and Participants

Adults who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between January 1, 2005, and September 30, 2015, within the National Patient-Centered Clinical Research Network. Data from 33 560 adults at 10 centers within 4 clinical data research networks were included in this cohort study. Information was extracted from electronic health records using a common data model and linked to insurance claims and mortality indices. Analyses were conducted from January 2018 through October 2019.

Exposures

Bariatric surgical procedures.

Main Outcomes and Measures

The primary outcome was time until operation or intervention. Secondary outcomes included endoscopy, hospitalization, and mortality rates.

Results

Of 33 560 adults, 18 056 (54%) underwent RYGB, and 15 504 (46%) underwent SG. The median (interquartile range) follow-up for operation or intervention was 3.4 (1.6-5.0) years for RYGB and 2.2 (0.9-3.6) years for SG. The overall mean (SD) patient age was 45.0 (11.5) years, and the overall mean (SD) patient body mass index was 49.1 (7.9). The cohort was composed predominantly of women (80%) and white individuals (66%), with 26% of Hispanic ethnicity. Operation or intervention was less likely for SG than for RYGB (hazard ratio, 0.72; 95% CI, 0.65-0.79; P < .001). The estimated, adjusted cumulative incidence rates of operation or intervention at 5 years were 8.94% (95% CI, 8.23%-9.65%) for SG and 12.27% (95% CI, 11.49%-13.05%) for RYGB. Hospitalization was less likely for SG than for RYGB (hazard ratio, 0.82; 95% CI, 0.78-0.87; P < .001), and the 5-year adjusted cumulative incidence rates were 32.79% (95% CI, 31.62%-33.94%) for SG and 38.33% (95% CI, 37.17%-39.46%) for RYGB. Endoscopy was less likely for SG than for RYGB (hazard ratio, 0.47; 95% CI, 0.43-0.52; P < .001), and the adjusted cumulative incidence rates at 5 years were 7.80% (95% CI, 7.15%-8.43%) for SG and 15.83% (95% CI, 14.94%-16.71%) for RYGB. There were no differences in all-cause mortality between SG and RYGB.

Conclusions and Relevance

Interventions, operations, and hospitalizations were relatively common after bariatric surgical procedures and were more often associated with RYGB than SG.

Trial Registration

ClinicalTrials.gov identifier: NCT02741674.

Short Bowel Syndrome after Laparoscopic Procedures

Short bowel syndrome (SBS) is a potential postoperative complication after intra-abdominal procedures. Whether the laparoscopic approach is as likely to result in SBS or the causative mechanisms are similar to open procedures is unknown. Our aim was to evaluate potential mechanisms of SBS after laparoscopic procedures. The records of 175 adult patients developing SBS as a postoperative complication were reviewed. One hundred forty-seven patients had open procedures and 28 laparoscopic. Colectomy (39%), hysterectomy (11%), and appendectomy (11%) were the most common open procedures. SBS followed laparoscopic gastric bypass (46%) and cholecystectomy (32%) most frequently. The mechanisms of SBS were different: adhesive obstruction (57 vs 22%, P < 0.05) was more common in the open group, whereas volvulus (18 vs 46%, P < 0.05) was more common after laparoscopy. Overall, ischemia (25 vs 32%) was similar but significantly more laparoscopic patients had postoperative hypoperfusion (32 vs 67%, P < 0.05). Eleven of the 13 laparoscopic bariatric procedures had internal hernias and volvulus. Of the nine patients undergoing cholecystectomy, four developed ischemia early postoperatively presumably secondary to pneumoperitoneum. SBS is an increasingly recognized complication of laparoscopic procedures. The mechanisms of intestinal injury differ from open procedures with a higher incidence of volvulus and more frequent ischemia from hypoperfusion.

Increased glycine-amidated hyocholic acid correlates to improved early weight loss after sleeve gastrectomy

BACKGROUND

Bile acids (BAs) are post-prandial hormones that play an important role in glucose and lipid homeostasis as well as energy expenditure. Total and glycine-amidated BAs increase after sleeve gastrectomy (SG) and correlate to improved metabolic disease. No specific bile acid subtype has been shown conclusively to mediate the weight loss effect. Therefore, the objective of this study was to prospectively evaluate the comprehensive changes in meal-stimulated BAs after SG and determine if a specific change in the BA profile correlates to the early weight loss response.

METHODS

Patients were prospectively enrolled at the University of Nebraska Medical Center who were undergoing a SG for treatment of morbid obesity. Primary and secondary plasma bile acids and their amidated (glycine, G-, or taurine, T-) subtypes were measured at fasting, 30 and 60 min after a liquid meal performed pre-op, and at 6 and 12 weeks post-op. Area under the curve (AUC) was calculated for the hour meal test for each bile acid subtype. BAs that were significantly increased post-op were correlated to body mass index (BMI) loss.

RESULTS

Total BA AUC was significantly increased at 6 (p < 0.01) and 12 weeks post-op (p < 0.01) compared to pre-operative values. The increase in total BA AUC was due to a statistically significant increase in G-BAs. Nine different BA AUC subtypes were significantly increased at both 6 and 12 weeks post-op. Increased total and G-chenodeoxycholic acid AUC was significantly correlated to the 6 week BMI loss (p = 0.03). Increased G-hyocholic acid was significantly correlated to increased weight loss at both 6 (p = 0.05) and 12 weeks (p = 0.006).

CONCLUSIONS

SG induced an early and persistent post-prandial surge in multiple bile acid subtypes. Increased G-hyocholic consistently correlated with greater early BMI loss. This study provides evidence for a role of BAs in the surgical weight loss response after SG.

Night Call Does Not Impair Learning of Laparoscopic Skills

Investigators have looked at the effect of night call on surgical residents but not at learning of laparoscopic skills. The Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) tests 6 tasks similar to a laparoscopic cholecystectomy. We hypothesized that night call would impair laparoscopic performance and that skills would not improve but rather deteriorate after night call. Seventeen volunteers were tested before and after night call. Data collected included economy of movement, time, and number of errors for each hand/foot. A paired Student t test was used for statistical analysis. On the first 2 tasks, there was an improvement in all parameters post-call, with significance reached in 5 of 18 parameters (P <.05). In the "running of the bowel," 8 of 9 parameters were significantly improved (P < .05). In the final task, 9 of 11 parameters showed a deterioration post-call, but only economy of movement of the foot was significant (P <.05). Most parameters (16) showed improvement rather than deterioration post-call, which is consistent with learning of laparoscopic skills despite lack of sleep from night call.

Predictors of Health-Related Quality of Life After Bariatric Surgery

BACKGROUND

Bariatric surgery is typically associated with improvement in health-related quality of life (HRQoL). However, recent reports are conflicting, and the aim of this study was to determine factors that would be predictive for long-term outcomes after bariatric procedures.

METHODS

One thousand five hundred and seventy-three patients at one Midwestern academic medical center who underwent any type of bariatric surgery were sent the SF-36 survey. Three hundred and fifty completed surveys collected over a 3-month period were returned. Multivariate analysis was conducted.

RESULTS

The physical and mental component scores were significantly lower than the norm population mean. Age at time of surgery, pre-surgical body mass index (BMI) and duration since surgery were negatively related to HRQoL.

CONCLUSIONS

Improvements in HRQoL following bariatric surgery do not appear to be sustained over the long term. Older patients and those with high pre-surgical obesity do not appear to have the same benefits in HRQoL over time.

Pilot Study on Childhood Sexual Abuse, Diurnal Cortisol Secretion, and Weight Loss in Bariatric Surgery Patients

Childhood sexual abuse increases risk for adult obesity. A potential contributing factor is altered cortisol secretion. In this pilot study, relationships among childhood sexual abuse, diurnal salivary cortisol secretion, and weight loss were explored in 17 bariatric surgery patients. Measurement points were before surgery (baseline) and 3 and 6 months after surgery. Childhood sexual abuse was measured by the Childhood Trauma Questionnaire. The results showed moderate but nonsignificant positive correlations between the childhood sexual abuse subscale score and baseline morning cortisol, evening cortisol, and daily mean cortisol. An unexpected positive correlation was noted between the Childhood Trauma Questionnaire total score and weight loss at six months. Diurnal cortisol secretion did not change over time after surgery nor correlate significantly with weight loss at six months.

Short bowel syndrome after laparoscopic procedures

Short bowel syndrome (SBS) is a potential postoperative complication after intra-abdominal procedures. Whether the laparoscopic approach is as likely to result in SBS or the causative mechanisms are similar to open procedures is unknown. Our aim was to evaluate potential mechanisms of SBS after laparoscopic procedures. The records of 175 adult patients developing SBS as a postoperative complication were reviewed. One hundred forty-seven patients had open procedures and 28 laparoscopic. Colectomy (39%), hysterectomy (11%), and appendectomy (11%) were the most common open procedures. SBS followed laparoscopic gastric bypass (46%) and cholecystectomy (32%) most frequently. The mechanisms of SBS were different: adhesive obstruction (57 vs 22%, P < 0.05) was more common in the open group, whereas volvulus (18 vs 46%, P < 0.05) was more common after laparoscopy. Overall, ischemia (25 vs 32%) was similar but significantly more laparoscopic patients had postoperative hypoperfusion (32 vs 67%, P < 0.05). Eleven of the 13 laparoscopic bariatric procedures had internal hernias and volvulus. Of the nine patients undergoing cholecystectomy, four developed ischemia early postoperatively presumably secondary to pneumoperitoneum. SBS is an increasingly recognized complication of laparoscopic procedures. The mechanisms of intestinal injury differ from open procedures with a higher incidence of volvulus and more frequent ischemia from hypoperfusion.

Impact of advanced laparoscopy courses on present surgical practice

Advanced laparoscopic workshops provide an efficacious instrument for educating surgeons in minimally invasive techniques.

Background and Objectives:

The introduction of new surgical techniques has made training in laparoscopic procedures a necessity for the practicing surgeon, but acquisition of new surgical skills is a formidable task. This study was conducted to assess the impact of advanced laparoscopic workshops on caseload patterns of practicing surgeons.

Methods:

After we obtained institutional review board approval, a survey of practicing surgeons who participated in advanced laparoscopic courses was distributed; the results were analyzed for statistical significance. The courses were held at the University of Nebraska Medical Center between January 2002 and December 2010. Questionnaires were mailed, faxed, and e-mailed to surgeons.

Results:

Of the 109 surgeons who participated in the advanced laparoscopy courses, 79 received surveys and 30 were excluded from the survey because of their affiliation with the University of Nebraska Medical Center. A total of 47 responses (59%) were received from 41 male and 6 female surgeons. The median response time from completion of the course to completion of the survey was 13.2 months (range, 6.8–19.1 months). The mean age of participating surgeons was 39.2 years (range, 29–51 years). The mean time since residency was 8.4 years (range, 0.8–21 years). Eleven surgeons had completed a minimal number of laparoscopic cases in residency (<50), 17 surgeons had completed a moderate number of laparoscopic procedures in residency (50–200), and 21 surgeons had completed a significant number of cases during residency (>200). Of the surgeons who responded, 94% were in private practice. Fifty-seven percent of the participating surgeons who responded reported a change in laparoscopic practice patterns after the courses. Of these surgeons, 24% had a limited residency laparoscopy exposure of <50 cases. Surgeons who were exposed to ≥50 laparoscopic cases during their residency showed a statistically significant increase in the number of laparoscopic procedures performed after their class compared with surgeons who did not receive ≥50 laparoscopic cases in residency (P = .03). In addition, regardless of the procedures learned in a specific class, surgeons with ≥50 laparoscopic cases in residency had a statistically significant increase in their laparoscopic colectomy and laparoscopic hernia procedure caseload (P < .01). However, there was no statistically significant difference in laparoscopic caseload between surgeons who had completed 50 to 200 laparoscopic residency cases and those who had completed greater than 200 laparoscopic residency cases (P = .31). Furthermore, the participant's age (P = .23), practice type (P = .61), and years in practice (P = .22) had no statistical significance with regard to the adoption of laparoscopic procedures after courses taken. This finding is congruent with the findings of other researchers. Future interest in advanced laparoscopy courses was noted in 70% of surgeons and was more pronounced in surgeons with ≥50 cases in residency.

Conclusion:

Advanced laparoscopic workshops provide an efficacious instrument in educating surgeons on minimally invasive surgical techniques. Participating surgeons significantly increased the number of course-specific procedures that they performed but also increased the number of other laparoscopic surgeries, suggesting that a certain proficiency in laparoscopic skills is translated to multiple surgical procedures. Laparoscopy experience of ≥50 cases during residency is a strong predictor of an increase in the number of advanced laparoscopic cases after attending courses.

Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) in the morbidly obese population is as high as 45%. The objective of this study was to compare the efficacy of various bariatric procedures in the improvement of GERD.

METHODS

The Bariatric Outcomes Longitudinal Database is a prospective database of patients who undergo bariatric surgery by a participant in the American Society of Metabolic and Bariatric Surgery Center of Excellence program. GERD is graded on a 6-point scale, from 0 (no history of GERD) to 5 (prior surgery for GERD). Patients with GERD severe enough to require medications (grades 2, 3, and 4) from June 2007 to December 2009 are identified; the resolution of GERD is noted based on 6-month follow-up.

RESULTS

Of a total of 116,136 patients, 36,938 patients had evidence of GERD preoperatively. After excluding patients undergoing concomitant hiatal hernia repair or fundoplication, there were 22,870 patients with 6-month follow-up. Mean age was 47.6±11.1 years, with an 82% female population. Mean BMI was 46.3±8.0 kg/m(2). Mean preoperative GERD score for patients with Roux-en-Y gastric bypass (RYGB) was 2.80±.56, and mean postoperative score was 1.33±1.41 (P<.0001). Similarly, adjustable gastric banding (AGB, 2.77±.57 to 1.63±1.37, P<.0001) and sleeve gastrectomy (SG, 2.82±.57 to 1.85±1.40, P<.0001) had significant improvement in GERD score. GERD score improvement was best in RYGB patients (56.5%; 7955 of 14,078) followed by AGB (46%; 3773 of 8207) and SG patients (41%; 240 of 585).

CONCLUSION

All common bariatric procedures improve GERD. Roux-en-Y gastric bypass is superior to adjustable gastric banding and sleeve gastrectomy in improving GERD. Also, the greater the loss in excess weight, the greater the improvement in GERD score.

Differences in outcomes of laparoscopic gastric bypass

BACKGROUND

Although several risk factors affecting weight loss outcomes with bariatric procedures have been identified, the effect of age, gender, race, and illness severity on postoperative outcomes of laparoscopic gastric bypass has not been extensively examined.

METHODS

The University HealthSystem Consortium database is an administrative and financial database that provides information on the inpatient stay. A retrospective analysis of patient outcomes was performed using 4-year discharge data from the University HealthSystem Consortium database.

RESULTS

A total of 37,765 patients underwent laparoscopic gastric bypass. The women exhibited significantly reduced mortality, morbidity, intensive care unit (ICU) admissions (9.87% male versus 6.73% female; P <.001), duration of hospitalization (2.72 ± 4.03 d for men versus 2.59 ± 2.88 d for women; P <.001), and hospital costs ($17,346 ± $15,397 for men versus $14,383 ± $11,170 for women; P <.001). Blacks demonstrated significantly greater 30-day readmission rates, duration of hospitalization, and costs compared with whites. Hispanics had lower ICU admission and hospital costs compared with whites. With increasing age, an increased risk of overall morbidity, ICU admissions, duration of hospitalization, and costs was observed. Compared with the minor severity group, the major/extreme severity group had significantly greater observed mortality, overall morbidity, ICU admissions, duration of hospitalization, and hospital costs.

CONCLUSION

The present study identified gender, race, age, and illness severity as risk factors affecting postoperative outcomes after laparoscopic gastric bypass. Male gender and increasing age were overall associated with an increased risk of complications. Significant racial disparities in the outcome measures were observed with blacks having an increased risk of adverse events. Illness severity was shown to adversely affect the surgical outcomes in laparoscopic gastric bypass.

Inferior vena cava filter placement for pulmonary embolism risk reduction in super morbidly obese undergoing bariatric surgery

BACKGROUND

Pulmonary embolism (PE) is a leading cause of mortality after bariatric surgery. We evaluated inferior vena cava (IVC) filter use for PE risk reduction in high-risk super morbidly obese bariatric surgery patients.

METHODS

IVC filters were inserted according to the patient's risk factors, including immobility, previous deep venous thrombosis (DVT)/PE, venous stasis, and pulmonary compromise. All filters were placed concomitant to bariatric surgery and were placed through a right internal jugular vein access site. We analyzed the prospectively collected data from this cohort and evaluated the incidence of PE and complications.

RESULTS

Since April 2003, 41 patients (12 men and 29 women) with a mean age of 47.3 +/- 10.0 years and body mass index of 64.2 +/- 12 kg/m2 (range 47-105) underwent IVC filter placement. These and all other patients underwent standard DVT/PE risk reduction measures. All IVC filter patients had one or more significant risk factors for thromboembolic events. No instances of PE were documented, although 1 patient experienced DVT, and no immediate or late complications related to filter placement occurred. One patient, with a body mass index of 105 kg/m2, died secondary to rhabdomyolysis after an extended procedure. The average filter placement time was 34.3 +/- 9 minutes.

CONCLUSION

IVC filter placement for PE risk reduction is safe and feasible in the super morbidly obese. Our data have shown that the filters can be placed expeditiously and with minimal morbidity concomitant with bariatric surgery. In this limited series, IVC filter placement was associated with no PE. Additional studies are needed to confirm the efficacy of IVC filter placement for PE risk reduction and related mortality in the super morbidly obese.

Comparison of conventional laparoscopic and hand-assisted oncologic segmental colonic resection

BACKGROUND

Laparoscopically assisted colon resection has evolved to be a viable option for the treatment of colorectal cancer. This study evaluates the efficacy of hand-assisted laparoscopic surgery (HALS) as compared with totally laparoscopic surgery (LAP) for segmental oncologic colon resection with regard to lymph node harvest, operative times, intraoperative blood loss, pedicle length, incision length, and length of hospital stay in an attempt to help delineate the role of each in the treatment of colorectal cancer.

METHODS

Patient charts were retrospectively reviewed to acquire data for this evaluation. Between June 2001 and July 2005, 40 patients underwent elective oncologic segmental colon resection (22 HALS and 18 LAP). The main outcome measures included lymph node harvest, operative times, intraoperative blood loss, pedicle length, incision length, and length of hospital stay.

RESULTS

The two groups were comparable in terms of demographics. The tumor margins were clear in all the patients. The HALS resection resulted in a significantly higher lymph node yield than the LAP resection (HALS: 16 nodes; range, 5-35 nodes vs LAP: 8 nodes; range, 5-22 nodes; p < 0.05) and significantly shorter operative times (HALS: 120 min; range, 78-181 min vs LAP: 156 min; range, 74-300 min; p < 0.05). Both groups were comparable with regard to length of hospital stay, pedicle length, and intraoperative blood loss. However, the LAP group yielded a significantly smaller incision for specimen extraction (LAP: 7 cm; range, 6-8 cm vs HALS: 5.5 cm; range, 5-7 cm; p < 0.05).

CONCLUSION

The findings suggest that hand-assisted laparoscopic oncologic segmental colonic resection is associated with shorter operative times, more lymph nodes harvested, and equivalent hospital stays, pedicle lengths, and intraoperative blood losses as compared with the totally laparoscopic approach. The totally laparoscopic technique was completed with a smaller incision. However, this less than 1 cm reduction in incision length has doubtful clinical significance.

Per-oral circular stapler in laparoscopic Roux-en-Y gastric bypass

Circular staplers are used to create the gastrojejunostomy of the Roux-en-Y gastric bypass. The anvil of the stapler can be placed within the pouch by way of the oropharynx or trans-abdominally, but these methods have limitations. The SurgASSIST Computer Mediated Stapler (Power Medical Interventions, New Hope, PA, USA) is a new technology that changes surgical stapling. The staplers are closed and fired under surgeon control by a computer for better accuracy and reliability. It has a 21-mm stapler, which can be passed orally for endoluminal stapling. The SurgASSIST has several advantages over the traditional circular stapled gastrojejunal anastomosis, including no need to dilate trocars to accommodate the stapler through the abdominal wall and decreased wound infections.

Feasibility of robot-assisted totally intracorporeal laparoscopic ileal conduit urinary diversion: initial results of a single institutional pilot study

OBJECTIVES

To explore the use of the da Vinci Surgical Robotic System (DSRS) to assist in the completion of totally intracorporeal laparoscopic ileal conduit urinary diversion (TLIC).

METHODS

Two patients with radiation cystitis underwent TLIC procedures and another patient with bladder cancer underwent TLIC along with laparoscopic radical cystoprostatectomy at our institution. The ileal conduit urinary diversion was done totally intracorporeally using conventional laparoscopic techniques, and the DSRS was used to assist in the Bricker-type ureteroileal anastomosis.

RESULTS

The 3 patients in the study included 2 men and 1 woman (mean age 73 years, range 64 to 84). The TLIC was completed intracorporeally in all 3 patients without the need for open conversion. The operative time, estimated blood loss, intraoperative decrease in hemoglobin, and time to hospital discharge for the 2 patients undergoing TLIC and the patient undergoing TLIC along with radical cystoprostatectomy was 628, 616, and 828 minutes, 50, 200, and 500 mL, 1.7, 2.8, and 5.3 g, and 5, 7, and 10 days, respectively. The median follow-up was 4.5 months (range 3.5 to 5.5). Postoperative satisfactory drainage of both kidneys was confirmed in all 3 patients at 8 weeks or later by intravenous urography or renal nuclear imaging. The serum creatinine remained stable in all 3 patients after surgery at hospital discharge. The only complication noted was postoperative ileus in the patient undergoing radical cystoprostatectomy that resolved with conservative management.

CONCLUSIONS

TLIC is technically feasible and safe and can be done intracorporeally without complications. The DSRS can be successfully used to assist in the completion of TLIC. However, that each case lasted for more than 600 minutes highlights the need for further refinement in the technique. The practical application of TLIC requires improved long-term outcomes compared with open surgery, as well as a reduction in the operative time to justify the costs of robotic surgery.