Preoperative Follow-up in Bariatric Surgery: Why They Give Up? Rate, Causes, and Economic Impact of Dropout

BACKGROUND

Preoperative attrition is highly prevalent in patients referred for bariatric surgery. Little information is available neither on reasons reported by patients for attrition in knowledge nor costs of attrition in a publicly funded health system.

OBJECTIVES

To assess the reasons for the attrition of bariatric candidates and calculate its economic impact on a population with obesity in a public hospital in France.

METHODS

This is a retrospective study including all bariatric surgery candidates between 2014 and 2018 in our Center of Excellence in Obesity Care. Data were extracted from the hospital information system, and patient-related outcomes were collected via a standardized questionnaire. Economic analysis was performed. Primary outcome was to analyze the rate of preoperative attrition. Secondary outcome was reasons for discontinuation and their economic impact.

RESULTS

In total, 1360 patients were referred for bariatric surgery at our hospital, and 1225 were included in the study. Attrition rate in preoperative phase was 46.8%. Three factors were significantly associated with follow-up fragmentation risk: unemployment (OR 0.52, 95% CI 0.29-0.7, p < 0.001), active smoking (OR 2.24, 95% CI 1.53-5.15, p < 0.001), and body mass index (OR 0.98, 95% CI 0.97-1.00, p = 0.036). Average cost to the healthcare system was €792 for each patient who dropped out.

CONCLUSIONS

We identified predictors and patient-reported factors that seem to be beyond the possibility of removal by health professionals. We should consider and address preventable factors, through the development of care pathways tailored to the individual profile of a patient.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

Endoscopic internal drainage for the management of leak, fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients

BACKGROUND

Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases.

OBJECTIVES

To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG.

SETTING

Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center.

METHODS

EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)-guided deployment of DPS or lumen apposing metal stents.

RESULTS

A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818).

CONCLUSION

Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.

Postoperative care fragmentation in bariatric surgery and risk of mortality: a nationwide study

BACKGROUND

Readmission after bariatric surgery may to lead to fragmentation of care if readmission occurs at a facility other than the index hospital. The effect of readmission to a nonindex hospital on postoperative mortality remains unclear for bariatric surgery.

OBJECTIVES

To determine postoperative mortality rates according to readmission destinations.

SETTING

Nationwide analysis of all surgical facilities in France.

METHODS

Multicenter, nationwide study of adult patients undergoing bariatric surgery from January 1, 2013, through December 31, 2018. Data from all surgical facilities in France were extracted from a national hospital discharge database.

RESULTS

In a cohort of 278,600 patients who received bariatric surgery, 12,760 (4.6%) were readmitted within 30 days. In cases of readmission, 23% of patients were admitted to a nonindex hospital. Patients readmitted to a nonindex facility had different characteristics regarding sex (men, 23.6% versus 18.2%, respectively; P < .001), co-morbidities (Charlson Co-morbidity Index, .74 versus .53, respectively; P < .001), and travel distance (38.3 km versus 26.9 km, respectively; P < .001) than patients readmitted to the index facility. The main reasons for readmission were leak/peritonitis and abdominal pain. The overall mortality rate after readmission was .56%. The adjusted odds ratio (OR) of mortality for the nonindex group was 4.96 (95% confidence interval [CI], 3.1-8.1; P < .001). In the subgroups of patients with a gastric leak, the mortality rate was 1.5% and the OR was 8.26 (95% CI, 3.7-19.6; P < .001).

CONCLUSION

Readmissions to a nonindex hospital are associated with a 5-fold greater mortality rate. The management of readmission for complications after bariatric surgery should be considered as a major issue to reduce potentially preventable deaths.

Intraperitoneal Tension-free Repair of a Small Midline Ventral Abdominal Wall Hernia: Randomized Study with a Mean Follow-up of 3 Years

Funding received from Cousin Biotech, Wervicq Sud, France, and CR Bard Inc., Cranston, RI. The aim of this prospective randomized study was to determine the long-term recurrence and complication rates after small abdominal wall hernia repair with two different bilayer prostheses. Hernia repair using prosthetic mesh material has become the preferred method of repair, because the recurrence rates are much lower than with conventional repair techniques. The use of a hernia bilayer patch, composite expanded polytetrafluoroethylene (ePTFE)-polypropylene, with intraperitoneal placement behind the hernia defect, through a small incision, may be efficient, safe, and cost-effective. This study is a randomized, single-institution trial, including 83 selected consecutive patients with primary (umbilical, epigastric) or incisional anterior abdominal wall defects from 2 to 5 cm. Hernia repair was performed by direct local access in ambulatory surgery; the prosthesis used was a circular bilayer with an inner face in ePTFE to avoid bowel adhesion. One group was treated with a Ventralex® Hernia Patch (Bard USA). The second group was treated with a Cabs'Air® Composite (Cousin Biotech France), which was delivered with two to four fixation sutures and a balloon to properly deploy the mesh intraperitoneally. Patients’ characteristics and operative and postoperative data were prospectively collected. The primary outcome was late recurrence. Secondary outcomes included, pain, discomfort and quality of life before and after (3 months) surgery using the SF-12 questionnaire, patient-surgeon satisfaction, and early and late complications. Among 98 patients, 83 were included in the study protocol between January 2007 and August 2011. The two groups were comparable according to pre- and intraoperative data. According to surgeon experience, placement of the Cabs'Air® device was significantly faster ( P = 0.01) and easier. At 3 months, there was significantly less pain and less discomfort for the Cabs'Air® group and patient satisfaction rate was higher. This was confirmed by all components of the SF-12 questionnaire. Long-term follow-up was available for 77 patients. The mean follow-up was similar for the two groups (42 months; range, 14 to 70 months). At this point, for the Ventralex® group, there were four recurrences (11.7%); one mesh infection; one small bowel obstruction; and six cases (15.7%) of severe pain resulting from a mass syndrome (shrinkage) with a sense of the presence of a foreign body. Six reoperations (15.6%) were required with explant of the prosthesis. There were no recurrences or late complications in the comparative group. The Ventralex® Hernia Patch is associated with inconsistent deployment, spreading, or shrinkage, which account for late complications and decreases the overlap, which contributes to the recurrence rate. The Cabs'Air®-associated balloon facilitates superior deployment of the prosthesis allowing for good fixation with four sutures.

Laparoscopic Sleeve Gastrectomy After Orthotopic Liver Transplantation, Video Reported

INTRODUCTION

The immunosuppressive therapy for life after liver transplantation (LT) is considered as a risk factor for obesity. Seven percent of the transplanted patients develop severe or morbid obesity. The obesity induces non-alcoholic steatohepatitis (NASH), which is a major risk factor for liver cirrhosis and hepatocellular carcinoma, without forgetting the cardiovascular risk and the devastating impact of obesity on quality of life of the transplanted patients. Consequently, obesity exposes these patients to future transplant loss. Bariatric surgery has been proposed for transplant patients to reduce the obesity-related comorbidities and to improve survival. We report in this video the surgical technique of laparoscopic sleeve gastrectomy (LSG) after LT.

METHODS

We have performed between 2008 and 2017 the sleeve gastrectomy (SG) after LT in nine patients. Six procedures (66%) were performed totally by laparoscopy and three by upfront laparotomy. All the patients had a standard preoperative evaluation for obesity. All the procedures were assisted by a hepatic surgeon. Postoperatively patients were transferred to the liver ICU for 24 h then to the liver unit ward.

RESULT

The median BMI was 41.9 kg/m² (range 38-46.1 kg/m²). Median operative time was 120 min (range, 90-240 min). No intra-operative complications occurred. The median length of hospital stay was 7 days (range, 4-81 days). The postoperative course of the majority of the patients was uneventful except for one patient who develops a staple line leak.

CONCLUSION

LSG after LT is technically feasible. Larger series are needed to improve the safety of the procedure in this high-risk population.

Total Gastrectomy with Roux-En-Y esophagojejunostomy for Chronic Complicated Post-Sleeve Gastric Fistula-Video Report

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) has become one of the most popular bariatric surgeries worldwide. However, complications related to the stapler line can be very serious. Among several challenging post-LSG complications, fistula is the most feared. Its management can be very challenging and chronic. In case of chronic fistula and failure of surgical, endoscopic, and radiological treatment, total gastrectomy with esojejunal anastomosis (RYOJ) can be considered as an effective solution. We describe in this video the steps of our laparoscopic technique.

METHODS

We have performed a total gastrectomy with RYOJ in a particular patient with chronic and persisting gastric fistula 9 months after LSG. The body mass index (BMI) was initially 50 kg/m² at the time of the LSG against 31 kg/m² on the day of the RYOJ.

RESULTS

The postoperative course was uneventful. An upper GI series was done at 1 week and 1 month postoperatively without any abnormality. The patient was evaluated clinically and biologically at 1, 3, and 6 months later on with no evidence of dysphasia or biological abnormality.

CONCLUSION

RYOJ in our particular case was efficient. However, longer series and longer follow-up are needed to confirm the effectiveness of this rescue procedure.

Intraperitoneal tension-free repair of a small midline ventral abdominal wall hernia: randomized study with a mean follow-up of 3 years

Funding received from Cousin Biotech, Wervicq Sud, France, and CR Bard Inc., Cranston, RI. The aim of this prospective randomized study was to determine the long-term recurrence and complication rates after small abdominal wall hernia repair with two different bilayer prostheses. Hernia repair using prosthetic mesh material has become the preferred method of repair, because the recurrence rates are much lower than with conventional repair techniques. The use of a hernia bilayer patch, composite expanded polytetrafluoroethylene (ePTFE)-polypropylene, with intraperitoneal placement behind the hernia defect, through a small incision, may be efficient, safe, and cost-effective. This study is a randomized, single-institution trial, including 83 selected consecutive patients with primary (umbilical, epigastric) or incisional anterior abdominal wall defects from 2 to 5 cm. Hernia repair was performed by direct local access in ambulatory surgery; the prosthesis used was a circular bilayer with an inner face in ePTFE to avoid bowel adhesion. One group was treated with a Ventralex® Hernia Patch (Bard USA). The second group was treated with a Cabs'Air® Composite (Cousin Biotech France), which was delivered with two to four fixation sutures and a balloon to properly deploy the mesh intraperitoneally. Patients' characteristics and operative and postoperative data were prospectively collected. The primary outcome was late recurrence. Secondary outcomes included, pain, discomfort and quality of life before and after (3 months) surgery using the SF-12 questionnaire, patient-surgeon satisfaction, and early and late complications. Among 98 patients, 83 were included in the study protocol between January 2007 and August 2011. The two groups were comparable according to pre- and intraoperative data. According to surgeon experience, placement of the Cabs'Air® device was significantly faster (P = 0.01) and easier. At 3 months, there was significantly less pain and less discomfort for the Cabs'Air® group and patient satisfaction rate was higher. This was confirmed by all components of the SF-12 questionnaire. Long-term follow-up was available for 77 patients. The mean follow-up was similar for the two groups (42 months; range, 14 to 70 months). At this point, for the Ventralex® group, there were four recurrences (11.7%); one mesh infection; one small bowel obstruction; and six cases (15.7%) of severe pain resulting from a mass syndrome (shrinkage) with a sense of the presence of a foreign body. Six reoperations (15.6%) were required with explant of the prosthesis. There were no recurrences or late complications in the comparative group. The Ventralex® Hernia Patch is associated with inconsistent deployment, spreading, or shrinkage, which account for late complications and decreases the overlap, which contributes to the recurrence rate. The Cabs'Air®-associated balloon facilitates superior deployment of the prosthesis allowing for good fixation with four sutures.

Geographical Information Systems and on-line GIServices for health data sharing and management

Integrating Geographical Information Systems (GIS) technology and public health experience may represent a solution for a better comprehension of spatial and temporal trends of phenomena. Useful applications can be built that support practitioners in their daily tasks, from risk assessment to prevention programmes. Also, making available data on the Internet through GIServices represents an important goal. Institutions and public health practitioners may benefit from the technological integration of GIS, the Web, handheld and mobile global positioning systems (GPS) devices. Expert users may be supported in deriving thematic maps which represent a spatial synthesis documentation starting from an analytic study expressed in terms of numbers and features. In this paper we show an example of an on-line data sharing and processing application, emphasizing ways GIS can provide added value to health research and management.