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Spurzem GJ, Broderick RC, Kunkel EK, Hollandsworth HM, Sandler BJ, Jacobsen GR, Horgan S. Robotic sleeve gastrectomy has higher complication rates compared to laparoscopic: 8-year analysis of robotic versus laparoscopic primary bariatric surgery. Surg Obes Relat Dis 2025; 21:372-381. [PMID: 39732583 DOI: 10.1016/j.soard.2024.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 11/13/2024] [Accepted: 11/23/2024] [Indexed: 12/30/2024]
Abstract
BACKGROUND Robotic-assisted bariatric surgery is growing rapidly. The optimal approach to minimize complications remains unclear. OBJECTIVE Assess robot utilization and compare 30-day outcomes for laparoscopic and robotic primary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. SETTING United States. METHODS A retrospective analysis of the MBSAQIP database identified primary SG and RYGB cases from 2015 to 2022. Revisions/conversions, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. Outcomes were compared with logistic regression following 1:1 propensity-score matching to adjust for differences in patient demographics/comorbidities and operative variables. RESULTS A total of 823,902 cases (591,118 SG; 232,784 RYGB) were included. From 2015 to 2022, the percentage of SG and RYGB performed robotically increased from 6.7% and 6.9% to 29.5% and 31.8%, respectively. Compared to laparoscopic, robotic SG had significantly higher overall morbidity (odds ratio 1.14 [1.07-1.21], P < .001), leak (1.24 [1.05-1.46], P = .03), and bleeding rates (1.34 [1.13-1.58], P < .001). Robotic RYGB had significantly lower overall morbidity (.75 [.70-.81], P < .001) and bleeding (.80 [.68-.94], P < .01) with similar leak rates (.87 [.71-1.07], P = .18). Combined robotic SG and RYGB outcomes were similar to laparoscopic for 2020-2022 cases, except for higher rates of organ/space infection, readmission, and septic shock in the robotic group. CONCLUSION Robotic SG has higher complication rates compared to laparoscopic, while robotic RYGB is protective against bleeding complications. Short-term outcomes for robotic surgery have become more similar to laparoscopic, but remain inferior. Further studies are warranted to elucidate the factors driving these findings.
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Affiliation(s)
- Graham J Spurzem
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, San Diego, California.
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Emily K Kunkel
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Hannah M Hollandsworth
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, San Diego, California
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Khan A, Layani L, Kiran N, Nasrullah B, Shchukina L, Noel P. Multicenter Perioperative Results with a New Endoscopic Powered Stapler in Bariatric Surgery: A Retrospective Study. J Laparoendosc Adv Surg Tech A 2025; 35:198-203. [PMID: 39829339 DOI: 10.1089/lap.2024.0358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2025] Open
Abstract
Background/Objectives: Advancements in surgical stapling devices play a crucial role in improving outcomes for bariatric procedures. This study evaluates the performance and safety of a new endoscopic stapler (EnDrive® BelugaTM) regarding perioperative results across multiple bariatric surgery types. Methods: A retrospective analysis was conducted on 112 patients who underwent bariatric procedures using the Beluga stapler at two centers in the United Arab Emirates and Kenya over a 6-month period (June-December 2023). Procedures included laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), one anastomosis gastric bypass-mini gastric bypass (OAGB-MGB), and revisions. Perioperative outcomes, complications, and hemoglobin changes were assessed. Results: The cohort included 29 males and 83 females, with a mean age of 32.8 years and preoperative body mass index of 41.1 kg/m2. Procedures performed were 88 primary LSG, 3 primary LRYGB, 12 primary OAGB-MGB, and 9 revision surgeries. No conversions, deaths, bleeding, or leaks occurred. Minor complications were observed in 4 patients. One patient required reoperation for intestinal obstruction. The mean hospital stay was 1.5 days. Hemoglobin levels showed minimal change from preoperative (12.8 g/dL) to postoperative day 1 (12.3 g/dL). Conclusions: The new Beluga endoscopic stapler demonstrated safe and effective performance across various bariatric procedures through this retrospective study, with low complication rates and minimal blood loss. Its enhanced articulation capabilities may offer advantages in specific cases. Further studies with larger groups, control groups, and longer follow-up periods are warranted to compare long-term outcomes with established stapling devices.
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Affiliation(s)
| | | | | | | | | | - Patrick Noel
- Nairobi Bariatric Center, Nairobi, Kenya
- Clinique Bouchard, Elsan, France
- Phi Medcare, Lusail, Qatar
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Cuva D, Park J, Chui P, Lipman J, Einersen P, Saunders JK, Parikh M. Comparison of Postoperative Bleed Rates and Location of Bleed Between Vessel Sealing Devices after Laparoscopic Sleeve Gastrectomy. J Laparoendosc Adv Surg Tech A 2025; 35:1-5. [PMID: 39189135 DOI: 10.1089/lap.2024.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2024] Open
Abstract
Background: Laparoscopic sleeve gastrectomy (SG) is a commonly performed bariatric procedure. At our institution, two vessel sealing devices, Thunderbeat® (Olympus) and Maryland LigaSure™ (Covidien) are utilized for intraoperative dissection. Methods: A retrospective review of all patients who underwent primary SG from July 2013 through August 2022 was performed to evaluate postoperative bleeding (POB) rates between the two devices. The primary outcome measured was POB as defined by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), with secondary outcomes including reoperation, source of bleed, and overall safety. Results: A total of 8157 underwent SG. Average BMI and age were 43.2 kg/m2 and 37.1 years, respectively. A total of 6600 (80.9%) were female. Thunderbeat® was utilized in 5143 (63%) cases and Maryland LigaSure™ was used in 3014 (37%) cases. There was no significant difference in overall bleeding between the Thunderbeat® (18/5143, .35%) and the Maryland LigaSure™ (19/3014, .63%; P = .0689). However, there was a difference noted when comparing reoperation for bleeding between Thunderbeat® (9/5143, .17%) and Maryland LigaSure™ (13/3014, .43%; P = .0291). Furthermore, the location of bleeding in the reoperations was more common from the cut edge of the mesentery compared to the staple line with the Maryland LigaSure™ versus the Thunderbeat® (P = .038). Conclusions: The Thunderbeat® device is comparatively more hemostatic than the Maryland LigaSure™ for SG. The location of postoperative bleed may be related to vessel sealing devices used.
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Affiliation(s)
- Dylan Cuva
- Department of Surgery, NYU Langone Medical Center, Bellevue Hospital Center, New York, New York, USA
| | - Julia Park
- Department of Surgery, NYU Langone Medical Center, Bellevue Hospital Center, New York, New York, USA
| | - Patricia Chui
- Department of Surgery, NYU Langone Medical Center, Bellevue Hospital Center, New York, New York, USA
| | - Jeffrey Lipman
- Department of Surgery, NYU Langone Medical Center, Bellevue Hospital Center, New York, New York, USA
| | - Peter Einersen
- Department of Surgery, NYU Langone Medical Center, Bellevue Hospital Center, New York, New York, USA
| | - John K Saunders
- Department of Surgery, NYU Langone Medical Center, Bellevue Hospital Center, New York, New York, USA
| | - Manish Parikh
- Department of Surgery, NYU Langone Medical Center, Bellevue Hospital Center, New York, New York, USA
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Kizilkaya MC, Basaran C, Kalafat UM, Mutlu AU, Saracoglu C, Aytac E. Resected gastric volume/number of staplers fired ratio as a tool in predicting complication and midterm results in sleeve gastrectomy. Sci Rep 2024; 14:30769. [PMID: 39730437 DOI: 10.1038/s41598-024-80600-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 11/19/2024] [Indexed: 12/29/2024] Open
Abstract
Laparoscopic sleeve gastrectomy is a restrictive surgery that aims to decrease the gastric volume of the patient. This study hypothesized that a higher resected gastric volume to the number of fired staplers ratio is associated with improved postoperative 12th-month outcomes. To analyze the effects of resected gastric volume to the number of fired staplers ratio on postoperative results in patients who underwent sleeve gastrectomy. University Hospital, Istanbul, Türkiye. We analyzed the data of 407 patients who underwent laparoscopic sleeve gastrectomy between 2018 and 2022. The primary outcome was the effect of resected gastric volume to the number of fired staplers ratio on excess weight loss at 12 months postoperatively. A total of 407 patients were included in the study. The higher resected gastric volume to the number of fired staplers ratio was associated with higher excess weight loss in the postoperative 12th month, while no significant effect was found on complications (p = 0.001 and p = 0.785, respectively). This study revealed resected gastric volume to the number of fired staplers ratio could be used to predict weight loss. Further studies should examine the effect of resected gastric volume to number of fired staplers ratio on postoperative complications.
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Affiliation(s)
| | | | - Utku Murat Kalafat
- University of Health Sciences Istanbul Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Arda Ulaş Mutlu
- Department of General Surgery, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Can Saracoglu
- Department of General Surgery, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Erman Aytac
- Department of General Surgery, Acıbadem University Atakent Hospital, Istanbul, Turkey.
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Spurzem GJ, Broderick RC, Kunkel EK, Hollandsworth HM, Sandler BJ, Jacobsen GR, Horgan S. Robotic bariatric surgery reduces morbidity for revisional gastric bypass when compared to laparoscopic: outcome of 8-year MBSAQIP analysis of over 40,000 cases. Surg Endosc 2024; 38:6294-6304. [PMID: 39179689 PMCID: PMC11525439 DOI: 10.1007/s00464-024-11192-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 08/17/2024] [Indexed: 08/26/2024]
Abstract
INTRODUCTION Robotic-assisted metabolic and bariatric surgery (MBS) is gaining popularity. Revisional MBS is associated with higher perioperative morbidity compared to primary MBS. The optimal surgical approach to minimize complications in these complex cases is unclear. The goal of this study was to assess robot utilization in revisional MBS and compare laparoscopic and robotic revisional MBS outcomes in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS A retrospective review of the MBSAQIP database was performed identifying revisional sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases from 2015 to 2022. Primary MBS, open/emergent cases, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. 30-Day outcomes for laparoscopic and robotic cases were compared using multivariate logistic regression adjusting for patient demographics, comorbidities, and operative variables. RESULTS 41,404 Cases (14,474 SG; 26,930 RYGB) were identified. From 2015 to 2022, the percentage of revisional SG and RYGB cases performed robotically increased from 6.1% and 7.3% to 24.2% and 32.0% respectively. Laparoscopic SG had similar rates of overall morbidity, leak, bleeding, readmission, reoperation, and length of stay compared to robotic. Laparoscopic RYGB had significantly higher rates of overall morbidity (6.2% vs. 4.8%, p < 0.001, AOR 0.80 [0.70-0.93]), blood transfusion (1.5% vs. 1.0%, p < 0.05, AOR 0.74 [0.55-0.99]), superficial incisional SSI (1.2% vs. 0.4%, p < 0.001, AOR 0.30 [0.19-0.47]), and longer length of stay (1.87 vs. 1.76 days, p < 0.001) compared to robotic. Laparoscopic operative times were significantly shorter than robotic (SG: 86.4 ± 45.8 vs. 113.5 ± 51.7 min; RYGB: 130.7 ± 64.7 vs. 165.5 ± 66.8 min, p < 0.001). CONCLUSION Robot utilization in revisional bariatric surgery is increasing. Robotic surgery has lower postoperative morbidity and shorter length of stay in revisional RYGB when compared to laparoscopic. Robotic platforms may have the capacity to improve the delivery of care for patients undergoing revisional bariatric surgery.
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Affiliation(s)
- Graham J Spurzem
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, 9300 Campus Point Dr La Jolla, San Diego, CA, 92037, USA.
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, 9300 Campus Point Dr La Jolla, San Diego, CA, 92037, USA
| | - Emily K Kunkel
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, 9300 Campus Point Dr La Jolla, San Diego, CA, 92037, USA
| | - Hannah M Hollandsworth
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, 9300 Campus Point Dr La Jolla, San Diego, CA, 92037, USA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, 9300 Campus Point Dr La Jolla, San Diego, CA, 92037, USA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, 9300 Campus Point Dr La Jolla, San Diego, CA, 92037, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, 9300 Campus Point Dr La Jolla, San Diego, CA, 92037, USA
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Chen JY, Shah S, Lloyd SJA, Pandya YK, Wooldridge J, Hage K, Kurian MS, Ghanem OM, Husain F, Kroh M. The SAGES masters program presents the 10 seminal articles for laparoscopic sleeve gastrectomy. Surg Endosc 2024; 38:5557-5566. [PMID: 39080061 DOI: 10.1007/s00464-024-11044-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/30/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program includes eight distinct clinical pathways. The Bariatric Surgery Pathway focuses on three anchoring procedures, including the laparoscopic sleeve gastrectomy (LSG) which is the most commonly performed bariatric procedure in the United States. In this article, we present and discuss the top 10 seminal articles regarding the LSG. METHODS The literature was systematically searched to identify the most cited papers on LSG. The SAGES Metabolic and Bariatric Surgery committee reviewed the most cited article list, and using expert consensus elected the seminal articles deemed most pertinent to LSG. These articles were reviewed in detail by committee members and are presented here. RESULTS The top 10 most cited sentinel papers on LSG focus on operative safety, outcomes, surgical technique, and physiologic changes after the procedure. A summary of each paper is presented, including expert appraisal and commentary. CONCLUSIONS The seminal articles presented support the widespread acceptance and use of the LSG by bolstering the understanding of its mechanism of action and by demonstrating its safety and excellent patient outcomes. All bariatric surgeons should be familiar with these 10 landmark articles.
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Affiliation(s)
- Judy Y Chen
- Department of Surgery, University of Washington, Seattle, WA, USA.
| | - Sajani Shah
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | | | - Yagnik K Pandya
- Department of Surgery, MetroWest Medical Center, Framingham, MA, USA
| | | | - Karl Hage
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Marina S Kurian
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Farah Husain
- Banner Health University Medical Center, Tucson, USA
| | - Matthew Kroh
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
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Fritz GD, Sharrak A, Aubrey J, Topalli X, Vrana A, Opalikihn A, Zambito GM, Martin TD, Foote JA, Smith JR, Schram JL. Perioperative Outcomes Using Single-Fire Stapler. Obes Surg 2024; 34:3553-3560. [PMID: 39106032 PMCID: PMC11349793 DOI: 10.1007/s11695-024-07357-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery performed worldwide. The Titan stapler aims to standardize the sleeve gastrectomy by eliminating inconsistencies and simplifying the procedure. METHODS A retrospective chart review was performed on all patients > 18 years of age undergoing LSG using the Titan. Pre-operative demographics, perioperative findings, and post-operative complications were all abstracted from the MBSAQIP database. RESULTS A total of 807 LSG have been performed using the latest iteration of the Titan stapler since November 2022. Data from these patients was compared to 3829 patients who underwent LSG using a sequential staple firing technique from September 2016-September 2021. The median age of Titan patients was 42 years (IQR 33-52) compared to 44 years (IQR 35-54) for sequential firing. The median pre-operative BMI was 47.1 (IQR 43.5-52.1) for Titan versus 47.6 (IQR 43.1-53.3) for sequential staple firing. After propensity matching, operative duration was significantly less for the Titan. Titan patients had decreased hospital length of stay, experienced fewer 30-day readmissions, and had less post-operative nausea/vomiting. Post-op bleed rates were similar between the two cohorts. Weight loss at 6 months favored the sequential fire arm, but our preliminary data shows this difference diminishes at 1 year. CONCLUSIONS Here we report our data on patients undergoing LSG using the latest Titan stapler. We show the device is safe, effective, and has resulted in an improvement in length of stay, readmissions, and post-operative nausea/vomiting. We also noted reduced operative time with this technique.
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Affiliation(s)
- Gregory D Fritz
- Corewell Health Department of General Surgery, 1900 Wealthy St SE, Suite 250, Grand Rapids, MI, 49506, USA.
| | - Aryana Sharrak
- Corewell Health - Grand Rapids/Michigan State University General Surgery Residency, Corewell Health, Grand Rapids, USA
| | - Jason Aubrey
- Corewell Health - Grand Rapids/Michigan State University General Surgery Residency, Corewell Health, Grand Rapids, USA
| | - Xhesika Topalli
- Michigan State University College of Human Medicine, Grand Rapids, USA
| | - Antonia Vrana
- Michigan State University College of Human Medicine, Grand Rapids, USA
| | - Anne Opalikihn
- Michigan State University College of Human Medicine, Grand Rapids, USA
| | - Giuseppe M Zambito
- Corewell Health Department of General Surgery, 1900 Wealthy St SE, Suite 250, Grand Rapids, MI, 49506, USA
| | - Thomas D Martin
- Corewell Health Department of Bariatric Surgery, Grand Rapids, USA
| | - James A Foote
- Corewell Health Department of Bariatric Surgery, Grand Rapids, USA
| | - Joshua R Smith
- Corewell Health Department of Bariatric Surgery, Grand Rapids, USA
| | - Jon L Schram
- Corewell Health Department of Bariatric Surgery, Grand Rapids, USA
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Braghetto I, Czwiklitzer G, Korn O, Brante P, Burgos A. RESULTS OF MECHANIC VERSUS MOTORIZED STAPLER USED IN GASTRIC SURGERY: PROSPECTIVE STUDY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1818. [PMID: 39230118 PMCID: PMC11363907 DOI: 10.1590/0102-6720202400025e1818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/02/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Mechanic sutures represent an enormous benefit for digestive surgery in decreasing postoperative complications. Currently, the advantages of motorized stapler are under evaluation. AIMS To compare the efficacy of mechanic versus motorized stapler in gastric surgery, analyzing rate of leaks, bleeding, time of stapling, and postoperative complications. METHODS Ninety-eight patients were submitted to gastric surgery, divided into three groups: laparoscopic sleeve gastrectomy (LSG) (n=47), Roux-en-Y gastric bypass (LRYGB) (n=30), and laparoscopic distal gastrectomy (LDG) (n=21). Motorized staplers were employed in 61 patients. The number of firings, number of clips, time of total firings, total time to complete the surgery, and postoperative outcome were recorded in a specific protocol. RESULTS Patients submitted to LSG, LRYGB, and LDG recorded a shorter time to complete the procedure and a smaller number of firings were observed using motorized stapler (p<0.0001). No differences were identified regarding the number of clips used in patients submitted to LSG. In the group that used mechanic stapler to complete gastrojejunostomy, jejuno-jejuno-anastomosis, and jejunal transection, it was observed more prolonged time of firing and total time for finishing the procedure (p=0.0001). No intraoperative complications were found comparing the two devices used. Very similar findings were noted in the group of patients undergoing LDG. CONCLUSIONS The motorized stapler offers safety and efficacy as demonstrated in prior reports and is relevant since less total time of surgical procedure without intraoperative or postoperative complications were confirmed.
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Affiliation(s)
- Italo Braghetto
- Digestive and Bariatric Surgical Unit, Redsalud Providencia, Santiago, Chile
| | - Gustavo Czwiklitzer
- Digestive and Bariatric Surgical Unit, Redsalud Providencia, Santiago, Chile
| | - Owen Korn
- Digestive and Bariatric Surgical Unit, Redsalud Providencia, Santiago, Chile
| | - Percy Brante
- Digestive and Bariatric Surgical Unit, Redsalud Providencia, Santiago, Chile
| | - Ana Burgos
- Digestive and Bariatric Surgical Unit, Redsalud Providencia, Santiago, Chile
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Fink M, Stock S, Fink JM, Seifert G, Broghammer V, Herrmann S, Fichtner-Feigl S, Marjanovic G, Laessle C. Effect of Intraoperative Blood Pressure Regulation on Postoperative Hemorrhage After Bariatric Surgery. Obes Surg 2024; 34:2446-2453. [PMID: 38769237 PMCID: PMC11217080 DOI: 10.1007/s11695-024-07275-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 05/05/2024] [Accepted: 05/09/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION With a rising number of bariatric procedures, the absolute number of postoperative complications is increasing, too. Postoperative bleeding, particularly along the staple line, is a recognized challenge. Numerous strategies including reinforcement of the staple line (SLR) have been proposed to improve bleeding rates, but no single technique has shown superiority over the others. In our bariatric center, we have implemented intraoperative blood pressure regulation alone, without SLR, to reduce hemorrhagic complications postoperatively. METHODS This retrospective observational analysis compares the incidence of postoperative bleeding in two groups of consecutive patients (total n = 438 patients), one with and one without intraoperative blood pressure elevation to 150 mmHg systolic without the additional use of staple line reinforcement. This intervention was integrated into our standard bariatric surgical procedure, no randomization or matching was conducted. Significant postoperative bleeding was defined as drop of hemoglobin of more than 2.5 mg/dl in 48 h and one of the following symptoms: lactate ≥ 2 mmol/L, bloody drainage, quantity of drainage more than 200 ml and/or radiological signs. RESULTS Defined postoperative bleeding occurred in 33 (7.5%) patients. We observed a decrease in bleeding rates from 10% to 5% (n = 22 vs. n = 11) after introducing intraoperative blood pressure increase (p = 0.034). The rate of revisional surgery for bleeding also decreased from 2.7% to 0.5% (n = 6 vs. n = 1). In multivariate analysis, the intervention with blood pressure elevation showed a significant decrease on bleeding rates (p = 0.038). CONCLUSION The use of increased intraoperative blood pressure alone, without staple line reinforcement, appears to be an effective and suitable method for reducing post-bariatric hemorrhagic complications.
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Affiliation(s)
- Mira Fink
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Shayda Stock
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Jodok Matthias Fink
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Gabriel Seifert
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Veit Broghammer
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Stephan Herrmann
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Goran Marjanovic
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Claudia Laessle
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.
- EXCEL Excellent Clinician Scientist Program, Else Kroener Research Schools for Physicians, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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10
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Vitiello A, Mok J, Elkalaawy M, Pucci A, Jenkinson A, Battheram R, Pilone V, Adamo M. Staple Line Reinforcement during Sleeve Gastrectomy with SeamGuard: Single-Center Retrospective Case-Control Study over a 5-Year Period. J Clin Med 2024; 13:3410. [PMID: 38929935 PMCID: PMC11203928 DOI: 10.3390/jcm13123410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/31/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Introduction: Various techniques and reinforcements have been proposed over the years in order to prevent leaks and bleeding after sleeve gastrectomy (LSG). The aim of this study was to retrospectively compare the staple line complication (SLC) rate in patients who underwent LSG with the use of bioabsorbable membrane (GORE® SEAMGUARD®, GoR) for staple line versus those who received no reinforcement. Methods: Data on all consecutive patients undergoing LSG between 1 January 2014 and 31 December 2018 were retrospectively reviewed. Patients were divided into two groups: the GoR+ group if the SeamGuard (GoR) was used and the GoR- group if no reinforcement was applied on the staple line. Preoperative demographics and rate of SLC were compared between groups. All cases of SLC coming from other centers were also reviewed. Results: A total number of 626 LSGs were performed at our institution during the study period. GoR was applied in 450 (71.9%) cases (GoR+ group), while NR was used in 176 (28.1%) patients (GoR- group). Two (1.13%) cases of leaking and two (1.13%) cases of bleeding occurred in the GoR- group, while no SLC was recorded in patients who received GoR (p < 0.05). Thirteen cases of SLC coming from other institutions were treated at our hospital; all these cases were performed without any SLR. Conclusion: In our case series, the use of GoR reduced the rate of SLC after LSG. In all cases of SLC coming from other institutions, no reinforcement had been applied on the staple line during LSG.
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Affiliation(s)
- Antonio Vitiello
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital (UCLH), London NW1 2BU, UK
- Advanced Biomedical Sciences Department, University of Naples Federico II, 80131 Naples, Italy
| | - Jessica Mok
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital (UCLH), London NW1 2BU, UK
| | - Mohamed Elkalaawy
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital (UCLH), London NW1 2BU, UK
| | - Andrea Pucci
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital (UCLH), London NW1 2BU, UK
| | - Andrew Jenkinson
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital (UCLH), London NW1 2BU, UK
| | - Rachel Battheram
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital (UCLH), London NW1 2BU, UK
| | - Vincenzo Pilone
- Public Health Department, University of Naples Federico II, 80131 Naples, Italy
| | - Marco Adamo
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital (UCLH), London NW1 2BU, UK
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11
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Triantafyllou E, Scholer V, Calabrese D, Ribeiro-Parenti L, Msika S, Rebibo L. Is Routine Post-operative Biological Laboratory Assessment Necessary After Sleeve Gastrectomy? Obes Surg 2024; 34:707-715. [PMID: 38273145 DOI: 10.1007/s11695-024-07065-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Incidence of post-operative complications after sleeve gastrectomy (SG) is low. However, the early identification of these complications remains crucial. Here, we report the impact of routine laboratory monitoring for the early diagnosis of complications after SG. MATERIAL AND METHODS From January 2018 to December 2019, all consecutive patients who underwent primary SG (n = 457) were included. This was a comparative study of patients undergoing primary SG. Patients were divided into two groups: one group with routine laboratory monitoring performed at postoperative day (POD) 1 and 3 (LAB group) and another group without routine laboratory monitoring (control group). The study's primary endpoint was the overall impact of routine laboratory monitoring. The secondary endpoints were evaluation of patients with complications. RESULTS The population in the two groups were similar in term of demographic and intra-operative data. There was a statistical difference between the two groups in term of length of stay (5.7 days in the LAB group and 3.5 days in the control group (p < 0.001)). There were 19 complications (6.0%) in the LAB group and 5 complications in the control group (3.5%) (p = 0.25). A cut-off C-reactive protein level of 46.3 mg/l was found to be significant (p = 0.006). In the LAB group, 9 patients (2.9%) required readmission vs. three patients (2.0%) in the control group (p = 0.62). CONCLUSION The interest of routine laboratory monitoring after SG seems limited. Routine laboratory monitoring alone is not associated with earlier diagnosis of complications. This routine monitoring is associated with an increase of stay in hospital.
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Affiliation(s)
- Evangelia Triantafyllou
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
| | - Vincent Scholer
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
- Service de Chirurgie, GHI Le Raincy-Montfermeil, 93370, Montfermeil, France
| | - Daniela Calabrese
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Lara Ribeiro-Parenti
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Simon Msika
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Lionel Rebibo
- Université de Paris, Inserm UMR 1149, 75018, Paris, France.
- Service de Chirurgie Digestive Et Oncologique, Hôpital Européen Georges Pompidou, APHP, 75015, Paris, France.
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12
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Chao GF, Nadzam G, Cheung M, Duffy A, Ghiassi S, Morton J. Collateral Benefit of Systematic Improvement in Bariatric Surgery Outcomes Following a Single Quality Improvement Project for Bleeding. Obes Surg 2024; 34:1041-1044. [PMID: 38280157 DOI: 10.1007/s11695-023-07037-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/08/2023] [Accepted: 12/26/2023] [Indexed: 01/29/2024]
Abstract
The study's aim was not only to use quality improvement system techniques to improve patient care specifically for bleeding but also to track other adverse outcomes. Key drivers were identified and mapped to interventions, namely venous thromboembolism prophylaxis, root cause analysis, indications conference, and operative technique standardization. Bleeding was reduced by 88%, and overall postoperative complications also fell by 63%. A targeted quality improvement project not only was effective in improving outcomes for the specific aim of bleeding but also resulted in improvement for other patient outcomes.
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Affiliation(s)
- Grace F Chao
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520, USA
| | - Geoffrey Nadzam
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520, USA
| | - Maija Cheung
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520, USA
| | - Andrew Duffy
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520, USA
| | - Saber Ghiassi
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520, USA
| | - John Morton
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520, USA.
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13
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Al-Tai S, Axer S, Szabo E, Ottosson J, Stenberg E. The impact of the bougie size and the extent of antral resection on weight-loss and postoperative complications following sleeve gastrectomy: results from the Scandinavian Obesity Surgery Registry. Surg Obes Relat Dis 2024; 20:139-145. [PMID: 37802662 DOI: 10.1016/j.soard.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/06/2023] [Accepted: 08/28/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND The optimal sleeve diameter and distance from the pylorus to the edge of the resection line in laparoscopic sleeve gastrectomy (LSG) remain controversial. OBJECTIVES To evaluate the influence of bougie size and antral resection distance from the pylorus on postoperative complications and weight-loss results in LSG. SETTING Nationwide registry-based study. METHODS This study included all LSGs performed in Sweden between 2012 and 2019. Data were obtained from the Scandinavian Obesity Surgery Registry. Reference bougie size of 35-36 Fr and an antral resection distance of 5 cm from the pylorus were compared to narrower bougie size (30-32 Fr), shorter distances (1-4 cm), and extended distances (6-8 cm) from the pylorus in assessing postoperative complications and weight loss as the outcomes of LSG. RESULTS The study included 9,360 patients with postoperative follow-up rates of 96%, 79%, and 50% at 30 days, 1 year, and 2 years, respectively. Narrow bougie and short antral resection distance from the pylorus were significantly associated with increased postoperative weight loss. Bougie size was not associated with increased early or late complications. However, short antral resection distance was associated with high risk of overall early complications [odds ratio: 1.46 (1.17-1.82, P = .001)], although no impact on late complications at 1 and 2 years was observed. CONCLUSIONS Using a narrow bougie and initiating resection closer to the pylorus were associated with greater maximum weight loss. Although a closer resection to the pylorus was associated with an increased risk of early postoperative complications, no association was observed with the use of narrow bougie for LSG.
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Affiliation(s)
- Saif Al-Tai
- Department of Surgery, Torsby Hospital, Torsby, Sweden; Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Stephan Axer
- Department of Surgery, Torsby Hospital, Torsby, Sweden; Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Eva Szabo
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Johan Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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14
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Sobutay E, Bilgiç Ç, Kabaoğlu B, Yavuz Y. Can Weight of The Resected Stomach Predict Weight Loss Results After Laparoscopic Sleeve Gastrectomy? Surg Laparosc Endosc Percutan Tech 2024; 34:29-34. [PMID: 38306493 DOI: 10.1097/sle.0000000000001260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/11/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure worldwide. Many factors have been investigated in the literature to predict weight loss outcomes after LSG. However, insufficient data regarding the resected stomach weight (RGW) exists. This retrospective study aimed to investigate the association between RGW and weight loss outcomes 1 year after LSG. MATERIALS AND METHODS Fifty-four patients who underwent LSG in a tertiary care center were evaluated retrospectively. The statistical analyses were performed to investigate the correlation between preoperative demographics, RGW, and the excess weight loss percentage (%EWL) and percent total weight loss (%TWL). RESULTS The mean RGW was 169.7±40.1, ranging from 101 to 295 grams. The RGW was significantly correlated with preoperative weight (r=0.486; P<0.001), body mass index (r=0.420; P=0.002), and age (r=0.327; P=0.01). However, RGW did not predict postoperative weight loss, as measured by percent total weight loss (%TWL) and percent excess weight loss (%EWL), respectively (r=0.044; P=0.75 and r=-0.216; P=0.11). Multiple linear regression analysis identified age as a negative predictor for both %TWL (β=-0.351, P=0.005) and %EWL (β=-0.265, P=0.03), while preoperative body mass index was a negative predictor for %EWL (β=-0.469, P<0.001). CONCLUSION The RGW, although correlated with patient characteristics, does not serve as a reliable predictor of postoperative weight loss in the first year after LSG. Further research is needed to improve predictive models and patient care in bariatric surgery.
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Affiliation(s)
- Erman Sobutay
- Department of General Surgery, Koç Foundation American Hospital
| | - Çağri Bilgiç
- Department of General Surgery, Koç Foundation American Hospital
| | - Burçak Kabaoğlu
- Department of General Surgery, Koç Foundation American Hospital
| | - Yunus Yavuz
- Department of General Surgery, Koç Foundation American Hospital
- Department of General Surgery, Obesity and Metabolic Surgery Center, Koç University, School of Medicine, Istanbul, Turkey
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15
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Albaugh VL. Comment on: Short-term cardiovascular events after bariatric surgery in patients with metabolic syndrome. Surg Obes Relat Dis 2024; 20:28. [PMID: 37783600 DOI: 10.1016/j.soard.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 10/04/2023]
Affiliation(s)
- Vance L Albaugh
- Metamor Institute, Pennington Biomedical Research Center, Baton Rouge, Louisiana
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16
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Perez SC, Ericksen F, Thaqi M, Richardson N, Wheeler AA. Concurrent paraesophageal hernia repair in revisional/conversional laparoscopic Roux-en-Y gastric bypass: propensity score-matched analysis of the MBSAQIP database. Surg Endosc 2023; 37:7955-7963. [PMID: 37439821 DOI: 10.1007/s00464-023-10268-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/29/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Patients requiring concurrent paraesophageal hernia repair (CPHR) have been shown to have favorable outcomes in primary bariatric surgery. However, patients requiring revisional or conversional surgery represent a group of patients with higher perioperative risk. Currently, few reports on concurrent paraesophageal hernia repair utilizing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database are available. The primary aim of this study was to determine perioperative complications associated with CPHR and the Roux-en-Y gastric bypass (RYGB) as a revisional/conversional operation. METHODS In this study, patients undergoing revisional/conversional RYGB between 2015 and 2020 were accessed via the MBSAQIP database. Patients were categorized based on the presence of a paraesophageal hernia as a concurrent procedure. Patients who underwent revisional/conversional surgery without additional procedures were utilized for controls. A propensity score-matched cohort was generated and E-analysis utilized to assess unmeasured confounding. RESULTS After exclusions, 35,698 patients were available. Patients receiving CPHR were more likely to be female (90.79% vs 87.37%; p < 0.001) and have increased frequency of gastroesophageal reflux disease (69.20% vs 51.69%; p < 0.001). However, these patients had lower frequencies of sleep apnea (24.12% vs 30.13%; p < 0.001), hypertension requiring medication (38.51% vs 42.59%; p < 0.001), and decreased frequency of hyperlipidemia (19.44% vs 21.60%;p < 0.001). After matching, 6,231 patient pairs were developed and showed that patients undergoing CPHR were at increased risk of readmission (9.44% vs 7.58%; p < 0.001), intervention (3.56% vs 2.79%; p = 0.018), increased requirement for outpatient dehydration treatment (5.87% vs 4.67%;p = 0.004), and overall increased operation time (169.3 min ± 76.0 vs 153.5 ± 73.3; p < 0.001). However, there were no significant increases in the rates of reoperation, death, postoperative leak complications, or bleeding complications after CPHR. CONCLUSION Patients undergoing revisional/conversional RYGB with CPHR may be at higher risk for a small number of rare postoperative complications. CPHR is a safe procedure in patients undergoing revisional/conversional RYGB in the short-term postoperative period.
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Affiliation(s)
- Samuel C Perez
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA.
| | - Forrest Ericksen
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Milot Thaqi
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Norbert Richardson
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Andrew A Wheeler
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
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17
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St Pierre J, Hajebian HH, Velasco C, Wooldridge J, Gorham J, Richardson WS. A Single-Institution 5-Year Retrospective Analysis of Laparoscopic Sleeve Gastrectomy Staple-Line Reinforcement: Bioabsorbable Mesh Versus Oversewing. J Laparoendosc Adv Surg Tech A 2023; 33:963-968. [PMID: 37615525 DOI: 10.1089/lap.2022.0551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
Background: Staple-line reinforcement has been used to decrease complications such as staple-line bleeding (SLB) and staple-line leaks (SLLs) in patients undergoing laparoscopic sleeve gastrectomy (SG). There is little data comparing bioabsorbable mesh reinforcement (BMR) with oversewing the staple line (OSL). The aim of our study was to compare BMR with OSL in SG. Materials and Methods: This is a single-institution retrospective analysis comparing risks and benefits of BMR (group a) with those of OSL (group b) for SG staple-line reinforcement between 2015 and 2020. Results: In total, 857 patients were identified. There were 452 (52.74%) in group a and 405 (47.26%) in group b. SLB requiring transfusion occurred in 6 (1.32%) patients in group a and 6 (1.48%) patients in group b, NS (P = .848). Zero SLL was identified in either group. One-year mean direct cost of SG in group a was $7881 compared with $6677 in group b. Conclusion: This retrospective study showed that there was low risk of bleeding or leak with either technique of staple-line reinforcement and there was no significant difference in SLB or leak rate with bioabsorbable mesh versus oversewing. The use of bioabsorbable mesh was more expensive than oversewing.
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Affiliation(s)
- Jesse St Pierre
- Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA
| | - H Harvak Hajebian
- Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA
| | - Cruz Velasco
- Department of General Surgery, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA
| | - James Wooldridge
- Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Jessica Gorham
- Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - William S Richardson
- Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
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18
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Cheng V, Grinberg GG, Ashbrook M, Silva J, Samakar K, Yenumula PR. Predictors of Complications Following Bariatric Surgery for Adolescent Patients. Am Surg 2023; 89:4031-4037. [PMID: 37171881 DOI: 10.1177/00031348231175463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Bariatric surgery for adolescent patients has been shown to be safe but potentially underutilized. A better understanding of operative risk in adolescents may temper apprehension to its adoption. This study intends to examine the association between preoperative risk factors and complications following bariatric surgery for adolescent patients. METHODS The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program databank (2015-2020) was queried for all adolescent patients (10 to 19 years). Only patients who underwent sleeve gastrectomy or gastric bypass were included. Multivariable regression examined the association between patient characteristics and complications. RESULTS A total of 7785 adolescent patients satisfied inclusion criteria. The median age was 18 years, 1737 (22%) were male, and the median body mass index was 46. Of all patients, 6675 (86%) and 1310 (14%) underwent sleeve gastrectomy and gastric bypass, respectively. Preoperative chronic steroid use was significantly associated with higher rates of leak (odds ratio [OR] 7.327, P = .009), bleeding (OR 10.791, P = .003), and reoperation (OR 7.685, P < .001). While Pacific Islander race was also significantly associated with higher rates of reoperation (OR 11.773, P = .039), Asian race was significantly associated with higher rates of bleeding (OR 14.527, P = .042). A history of gastroesophageal reflux disease was associated with higher rates of postoperative reintervention (OR 2.306, P = .004). DISCUSSION Readily identifiable preoperative patient characteristics are significantly associated with higher rates of postoperative complications following adolescent bariatric surgery. Additional research is required to determine whether tailoring treatment based on these characteristics can improve outcomes.
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Affiliation(s)
- Vincent Cheng
- Department of Bariatric Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Gary G Grinberg
- Department of Bariatric Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Matthew Ashbrook
- Division of Upper GI and General Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Jack Silva
- Division of Upper GI and General Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kamran Samakar
- Department of Bariatric Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Panduranga R Yenumula
- Department of Bariatric Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
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19
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Li M, Zeng N, Liu Y, Sun X, Yang W, Liu Y, Mao Z, Yao Q, Zhao X, Liang H, Lou W, Ma C, Song J, Wu J, Yang W, Zhang P, Zhu L, Tian P, Zhang P, Zhang Z. Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry. Chin Med J (Engl) 2023; 136:1967-1976. [PMID: 37525550 PMCID: PMC10431592 DOI: 10.1097/cm9.0000000000002499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting. METHODS To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks. RESULTS A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor. CONCLUSIONS Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.
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Affiliation(s)
- Mengyi Li
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Na Zeng
- School of Public Health, Peking University, Beijing 100191, China
| | - Yang Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Xitai Sun
- Department of General Surgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu 210008, China
| | - Wah Yang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
| | - Yanjun Liu
- Center of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, The Third People's Hospital of Chengdu & The Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan 610014, China
| | - Zhongqi Mao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Qiyuan Yao
- Center for Obesity and Metabolic Surgery, Huashan Hospital, Fudan University, Shanghai 200030, China
| | - Xiangwen Zhao
- Department of Metabolic and Bariatric Surgery, Xiaolan People's Hospital of Zhongshan, Zhongshan, Guangdong 528415, China
| | - Hui Liang
- Department of General Surgery, First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 226399, China
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital, Shanghai 200032, China
| | - Chiye Ma
- Department of Gastrointestinal Surgery, Dongfang Hospital of Shaghai, Shanghai 200120, China
| | - Jinghai Song
- Department of General Surgery, Beijng Hospital, Beijing 100730, China
| | - Jianlin Wu
- Department of Gastrointestinal Surgery, Zibo Central Hospital, Zibo, Shandong 255020, China
| | - Wei Yang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Pin Zhang
- Department of Bariatric and Metabolic Surgery, Shanghai Jiao Tong University affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Liyong Zhu
- Department of Gastrointestinal Surgery,The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, China
| | - Peirong Tian
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Peng Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
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20
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Toniolo I, Berardo A, Gagner M, Foletto M, Carniel EL. Unveiling the effects of key factors in enhancing gastroesophageal reflux: A fluid-structure analysis before and after laparoscopic sleeve gastrectomy. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 231:107409. [PMID: 36780716 DOI: 10.1016/j.cmpb.2023.107409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Gastro-oesophageal reflux disease (GERD) consists in the passage of gastric acid content from the stomach to the oesophagus, causing burns and deteriorating the quality of life. Laparoscopic Sleeve Gastrectomy (LSG) could induce de novo GERD and worsen pre-existing GERD because of the higher gastric pressurisation, reduction of stomach volume and a wider His-angle. In the proposed work, various computational gastric 2D models were developed to understand the effects of variables such as the His-angle, the antral dimension, and the bolus viscosity on the reflux increase. METHODS Fluid-Structure Interaction (FSI) computational models which couple the solid mechanics of the gastric wall, and the fluid domain of the bolus, have been developed to shed light on biomechanical aspects of GERD after LSG. A closure was imposed to the lower oesophageal sphincter (LES) mimicking what happens physiologically after food intake. RESULTS Results showed that the configuration prone to higher reflux flow was the post-surgical 65° model with a staple line starting directly from the pylorus without antral preservation, for all considered viscosities. Increasing viscosity, reflux flow decreased. Post-surgical refluxes were higher than pre-ones and decreased with increasing antrum preservation. CONCLUSIONS These results could be a starting point for analysis of anatomical features, bariatric surgery and GERD occurrence. Further studies based on 3D geometries need to be performed.
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Affiliation(s)
- Ilaria Toniolo
- Department of Industrial Engineering, University of Padova, Italy; Centre for Mechanics of Biological Materials, University of Padova, Italy
| | - Alice Berardo
- Centre for Mechanics of Biological Materials, University of Padova, Italy; Department of Civil, Environmental and Architectural Engineering, University of Padova, Italy; Department of Biomedical Sciences, University of Padova, Italy.
| | - Michel Gagner
- Department of Surgery, Hôpital du Sacré-Coeur de Montréal, Canada
| | - Mirto Foletto
- Centre for Mechanics of Biological Materials, University of Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy; IFSO Bariatric Centre of Excellence, Policlinico Universitario, University of Padova, Italy
| | - Emanuele Luigi Carniel
- Department of Industrial Engineering, University of Padova, Italy; Centre for Mechanics of Biological Materials, University of Padova, Italy
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Mocanu V, Verhoeff K, Sinclair K, Birch DW, Karmali S, Switzer NJ. Atrial dysrhythmias are independent predictors of serious complications and 30-day mortality after elective bariatric surgery: a retrospective study of 731,981 patients. Surg Obes Relat Dis 2023; 19:204-211. [PMID: 36257894 DOI: 10.1016/j.soard.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/25/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVES The objectives of this study were to characterize the prevalence of atrial dysrhythmias for elective bariatric surgery patients and to explore their impact on postoperative outcomes. SETTING Data was extracted from the North American Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2019. METHODS All primary Roux-en-Y gastric bypass and sleeve gastrectomy procedures were included. Patients with atrial dysrhythmias (ADs) were identified as patients coded as receiving preoperative therapeutic anticoagulation without a prior history of deep vein thrombosis, venous thromboembolism, pulmonary embolism, or other conditions requiring anticoagulation. Multivariable logistic regression analysis was used to determine the impact of preoperative ADs on postoperative complications and 30-day mortality. RESULTS We evaluated 731,981 patients, of whom 13,591 (1.9%) had preoperative ADs. Patients with ADs were more likely to be older, have a higher body mass index, and be male. Metabolic co-morbidities also were more common in those with ADs, as demonstrated by the higher rates of medication use and insulin-dependent diabetes, hypertension, dyslipidemia, and sleep apnea. After adjusting for co-morbidities using multivariable logistic regression, AD was the single greatest independent predictor of serious complications and 30-day mortality. CONCLUSIONS ADs were observed in approximately 2% of MBSAQIP patients. ADs are among the greatest independent predictors of serious complications and mortality, suggesting that these patients are associated with a higher perioperative risk profile warranting further optimization.
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Affiliation(s)
- Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Kirk Sinclair
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel W Birch
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Shahzeer Karmali
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Noah J Switzer
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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22
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Aboueisha MA, Evans L, Allotey JK, Biagini EK, Freeman M, Caposole MZ, Baker JW, Galvani C, Levy S. A 5-year propensity-matched analysis of perioperative outcomes in patients with chronic kidney disease undergoing bariatric surgery. Surg Endosc 2023; 37:2335-2346. [PMID: 36401102 DOI: 10.1007/s00464-022-09756-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bariatric surgery can improve renal function in patients with comorbid chronic kidney disease (CKD) and obesity. Additionally, bariatric surgery can enhance outcomes following renal transplantation. The safety of bariatric surgery in patients with CKD has been debated in the literature. This study evaluates the frequency of perioperative complications associated with CKD. METHODS The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried from 2015-2019. Patients were included if they had a vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) and were stratified based on CKD status. An unmatched and propensity-matched analysis was performed comparing 30-day perioperative outcomes between the groups. RESULTS A total of 717,809 patients included in this study, 5817(0.8%) had CKD, of whom 2266(0.3%) were on dialysis. 74.3% of patients with CKD underwent VSG with 25.7% underwent RYGB. Comparing RYGB to VSG, patients who underwent RYGB had a higher rate of deep organ space infection (0.7%vs.0.1%,p = 0.021) and re-intervention (5.0% vs. 2.2%,p < 0.001). Within the VSG cohort, a matched analysis was performed for those with CKD and without CKD. The CKD cohort had higher risk of complications such as bleeding (2.1%vs. 0.9%,p < 0.001), readmission (9.3%vs.4.9%,p < 0.001), reoperation (2.7%vs.1.3%,p < 0.001), and need for reintervention (2.2%vs.1.3%,p < 0.001). Notably, patients with CKD also had a higher mortality (0.6%vs.0.2%,p = 0.003). No difference was seen between patients with renal insufficiency and patients on dialysis. CONCLUSION VSG has been the operation of choice in patients with CKD. Our results showed it is the safer option for patients with CKD compared to RYGB. Although this patient population does have an increased risk of adverse perioperative events, dialysis didn't affect the outcome. Bariatric surgeons who operate on patients with CKD should be well informed and remain vigilant given the increased perioperative risk. The risk is still considerably low, and the potential benefit on renal function and improvement in candidacy for renal transplant outweigh the risk. They should be considered as surgical candidates.
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Affiliation(s)
- Mohamed A Aboueisha
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA
| | - Leah Evans
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA
| | - Jonathan K Allotey
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA
| | - Emily K Biagini
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA
| | - Meredith Freeman
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA
| | - Michael Z Caposole
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA.
| | - John W Baker
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA
| | - Carlos Galvani
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA
| | - Shauna Levy
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA
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23
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Yapalak Y, Yigman S, Gonultas C, Coskun H, Yardimci E. The Effects of the Staple Line Reinforcement Procedures on Gastrointestinal Symptoms and Its Early Results in Sleeve Gastrectomy. J Laparoendosc Adv Surg Tech A 2023; 33:162-170. [PMID: 36006657 DOI: 10.1089/lap.2022.0210] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The laparoscopic sleeve gastrectomy (LSG) procedure is the most common bariatric surgical technique worldwide, but controversy continues over staple line reinforcement (SLR) techniques. This prospective randomized study aimed to compare the effects of SLR methods on early postoperative complications and gastrointestinal symptoms in patients undergoing LSG for morbid obesity. Materials and Methods: Ninety patients who underwent LSG surgery for obesity between June 2019 and February 2020 in the Department of General Surgery of Bezmialem Vakıf University were included in our prospective randomized study. According to the SLR techniques, three groups were determined as Group 1: using fibrin sealant (Tisseel®), Group 2: omentopexy, Group 3: no SLR, with each group having 30 randomly assigned patients. Gastrointestinal symptoms were assessed by performing the Gastrointestinal Symptom Rating Scale (GSRS) for all patients following the first week and first month. On the second postoperative day, all patients underwent swallow-graphy to investigate twists and fistula. Results: The test group included 90 patients totally, of which 17 are males and 73 are females with a mean age of 35.3 ± 11.6 years and a mean body mass index of 45.3 ± 7.7 kg/m2. According to the GSRS, reflux and indigestion scores in Group 3 were significantly higher than those in the other groups in the first week (P < .001). There was no statistically significant difference in abdominal pain scores in the first week. Group 3's operation time was statistically significantly shorter than the other groups (Group 1 P = .005; Group 2 P = .001). In Group 3, 2 patients (2.2%) had bleeding. There was no mortality. There were no twists or fistulas found in swallow graphs. Symptomatic reflux was not observed in the first-year follow-up period. Conclusions: SLR methods reduce gastrointestinal system complaints in the early postoperative period. In our study, omentopexy and fibrin sealant used in LSG did not show a statistically significant difference in early postoperative complications.
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Affiliation(s)
- Yunus Yapalak
- Department of General Surgery, Bezmialem Vakıf University, Istanbul, Turkey
| | - Samet Yigman
- Department of General Surgery, Bezmialem Vakıf University, Istanbul, Turkey
| | - Ceren Gonultas
- Department of General Surgery, Bezmialem Vakıf University, Istanbul, Turkey
| | - Halil Coskun
- Department of General Surgery, Bezmialem Vakıf University, Istanbul, Turkey
| | - Erkan Yardimci
- Department of General Surgery, Bezmialem Vakıf University, Istanbul, Turkey
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24
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The Effect of Sizing Device Use During Laparoscopic Sleeve Gastrectomy on Rates of Postoperative Dehydration and Other 30-day Complications: An Analysis of the ACS-MBSAQIP Database. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:55-61. [PMID: 36728205 DOI: 10.1097/sle.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND During laparoscopic sleeve gastrectomy (LSG), many surgeons use an intraoperative sizing device. However, the choice of intraoperative sizing device varies and the optimal choice or combination of sizing devices, such as a bougie or esophagogastroduodenoscopy (EGD), is not known. The purpose of this study was to determine if there is an association between the use of a sizing device or a combination of sizing devices on rates of dehydration, bleeding, and staple line leak following LSG. MATERIALS AND METHODS Patients between the ages of 18 to 80 who underwent elective LSG were identified using the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (ACS-MBSAQIP) database from 2015 to 2019. Postoperative outcomes, including rates of dehydration, bleeding, and staple line leak, were compared across 4 groups: those that utilized bougie and EGD (both), those that utilized only bougie (bougie only), those that utilized only EGD (EGD only), and those that did not utilize either sizing device (neither). RESULTS In all, 533,151 cases met the inclusion criteria. On univariate analysis, the bougie-only group experienced the highest rates of dehydration events. On multivariate analysis, the use of both sizing devices was associated with significantly lower odds of events related to dehydration versus bougie only (aOR 0.869, P =0.0002), and bougie only was associated with significantly higher odds of events related to dehydration versus EGD only (aOR 1.773, P =0.0006).The neither-sizing device group did not show any statistically significant differences in any of the comparisons. CONCLUSIONS Bougie use alone was associated with more dehydration-related complications, while EGD use demonstrated a protective effect. Not using a sizing device was associated with equivalent outcomes to all combinations of sizing devices. These findings highlight the need for the standardization of sizing devices during LSG and suggest that foregoing sizing devices may be a management option without early adverse sequelae.
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25
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Comparison of robot-assisted sleeve gastrectomy outcomes in multiple staple line treatment modalities from 2015 to 2019: a 5-year propensity score-adjusted MBSAQIP® analysis. Surg Endosc 2023; 37:1401-1411. [PMID: 35701675 DOI: 10.1007/s00464-022-09366-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/22/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Robot-assisted sleeve gastrectomy (RSG) is an increasingly common approach to sleeve gastrectomy (SG). Staple line reinforcement (SLR) is well-discussed in laparoscopic SG literature, but not RSG- likely due to the absence of dedicated robotic SLR devices. However, most RSG cases report SLR. This retrospective analysis compares outcomes in RSG cases reporting (1) any staple line treatment (SLT) vs none and (2) SLR vs oversewing. METHODS MBSAQIP was queried for adults who underwent RSG from 2015 to 2019. Open procedures, Natural Orifice Transluminal Endoscopic Surgery, hand-assisted, single-incision, concurrent procedures, and illogical BMIs were excluded (n = 3444). Final sample included 52,354 patients. Two comparisons were made: SLT (n = 34,886) vs none (n = 17,468) and SLR (n = 22,217) vs oversew (n = 5620). We fitted multivariable regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) and performed propensity score analysis with inverse probability of treatment weight based on patient factors. RESULTS Most RSG cases utilized SLT (66.6%). Cases with SLT had a reduced risk of organ space SSI (RR 0.68 [0.49, 0.94]), 30-day reoperation (RR 0.77 [0.64, 0.93]), 30-day re-intervention (RR 0.80 [0.67, 0.96]), sepsis (RR 0.58 [0.35, 0.96]), unplanned intubation (RR 0.59 [0.37, 0.93]), extended ventilator use (RR 0.46 [0.23, 0.91]), and renal failure (RR 0.40 [0.19, 0.82]) compared to no-treatment cases. In single-treatment cases (n = 27,837), most utilized SLR (79.8%). Cases with oversew had a higher risk of any SSI (RR 1.70 [1.19, 2.42]), superficial incisional SSI (RR 1.71 [1.06, 2.76]), septic shock (RR 6.47 [2.11, 19.87]), unplanned intubation (RR 2.18 [1.06, 4.47]), and extended ventilator use (> 48 h) (RR 4.55 [1.63, 12.71]) than SLR. CONCLUSIONS Our data suggest SLT in RSG is associated with reduced risk of some adverse outcomes vs no-treatment. Among SLT, SLR demonstrated lower risk than oversewing. However, risk of all-cause mortality, cardiac arrest, and unplanned ICU admission were not significant.
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Sleeve gastrectomy morphology and long-term weight-loss and gastroesophageal reflux disease outcomes. Surg Endosc 2023:10.1007/s00464-022-09555-6. [PMID: 36645483 DOI: 10.1007/s00464-022-09555-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/08/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND The relationship between sleeve gastrectomy (SG) morphology and long-term weight-loss and gastroesophageal reflux disease (GERD) outcomes is unknown. METHODS All patients (n = 268) undergoing SG performed by 3 surgeons at a single academic institution from January 1, 2010 to December 31, 2012 were included. Long-term weight-loss and GERD outcomes were available for 90 patients which were incorporated in analyses. SG morphology was determined from postoperative day 1 upper gastrointestinal series (UGIS) available from 50 patients. Images were independently categorized using previously published methodology as Dumbbell (38%), Lower Pouch (22%), Tubular (26%), or Upper Pouch (14%) by Radiologist and Surgeon. Radiologist categorization was used when disagreement occurred (8%). Univariable analyses were conducted to explore potential associations between SG morphology, weight loss, and GERD outcomes. RESULTS Follow-up was 8.2 ± 0.9 years. Population characteristics included age of 45.1 ± 10.8 years, female sex in 83.3%, and hiatal hernia repair (HHR) performed at index SG in 17.8%. Surgeons did not preferentially achieve a specific SG morphology. Changes from preoperative obesity and associated diseases comprised body mass index (BMI) (49.5 ± 7.6 vs. 39.2 ± 9.4 kg/m2; p < 0.0001), diabetes mellitus (30.0 vs. 12.2%; p = 0.0006), hypertension (70.0 vs. 54.4%; p = 0.0028), hyperlipidemia (42.2 vs. 24.2%;p = 0.0017), obstructive sleep apnea (41.1 vs. 15.6%; p < 0.0001), osteoarthritis (48.9 vs. 13.3%; p < 0.0001), back pain (46.5 vs. 28.9%; p = 0.0035), and medications (4.8 ± 3.3 vs. 3.7 ± 3.5; p < 0.0001). Dumbbell SG morphology was associated with lesser reduction in BMI at follow-up (--6.8 ± 7.2 vs. -12.4 ± 8.3 kg/m2; p = 0.0196) while greater BMI change was appreciated with Lower Pouch SG shape (-16.9 ± 9.9 vs. -8.4 ± 6.8 kg/m2; p = 0.0017). GERD was more prevalent at follow-up than baseline (67.8 vs. 47.8%; p < 0.0001). GERD-specific outcomes included de novo (51.1%), persistent (27.9%), worsened (58.1%), and resolved (14.0%) disease. Ten patients underwent reoperation for refractory GERD with SG morphology corresponding to Dumbbell (n = 5) and Upper Pouch (n = 1) for those with available UGIS. Univariable analyses showed that patients with GERD experienced a larger reduction in BMI compared with patients without GERD (-11.8 ± 7.7 vs. -7.0 ± 5.1 kg/m2; p = 0.0007). Patient age, surgeon, morphology category, and whether a HHR was done at index SG were not associated with the presence of any, de novo, or worsened GERD. Female sex was associated with worsened GERD (96.0 vs. 4.0%; p = 0.0455). Type of calibration device, distance from staple line to pylorus, and whether staple line reinforcement was used were not associated with SG morphology classification. CONCLUSION This is the first study assessing the impact of SG morphology on long-term weight loss and GERD. Our data suggest an association between SG morphology and long-term weight loss but not with GERD outcomes. Current technical standards may be limited in reproducing the same SG morphology. This information may help guide the technical optimization and standardization of SG. Surgeons did not favor a specific SG morphology (1). Our results signal to a relationship between radiographic assessment of SG morphology and long-term weight-loss outcomes with Dumbbell classification correlated with lesser reduction in BMI (2a) and Lower Pouch morphology associated with superior weight loss (2b). SG, sleeve gastrectomy; BMI, body mass index.
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Highet A, Johnson EH, Bonham AJ, Hutton DW, Zhou S, Thalji AS, Ghaferi AA. Cost-effectiveness of Staple Line Reinforcement in Laparoscopic Sleeve Gastrectomy. Ann Surg 2023; 277:121-126. [PMID: 34029226 DOI: 10.1097/sla.0000000000004950] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To perform a cost-effectiveness analysis of staple-line reinforcement in laparoscopic sleeve gastrectomy. SUMMARY OF BACKGROUND DATA Exponential increases in surgical costs have underscored the critical need for evidence-based methods to determine the relative value of surgical devices. One such device is staple-line reinforcement, thought to decrease bleeding rates in laparoscopic sleeve gastrectomy. METHODS Two intervention arms were modeled, staple-line reinforcement and standard nonreinforced stapling. Bleed and leak rates and 30-day treatment costs were obtained from national and state registries. Quality-adjusted life-year (QALY) values were drawn from previous literature. Device prices were drawn from institutional data. A final incremental cost-effectiveness ratio was calculated, and one-way and probabilistic sensitivity analyses were performed. RESULTS A total of 346,530 patient records from 2012 to 2018 were included. Complication rates for the reinforced and standard cohorts were 0.05% for major bleed in both cohorts ( P = 0.8841); 0.45% compared with 0.59% for minor bleed ( P < 0.0001); and 0.24% compared with 0.26% for leak ( P = 0.4812). Median cost for a major bleed was $5552 ($3287, $16,817) and $2406 ($1861, $3484) for a minor bleed. Median leak cost was $9897 ($4589, $21,619) and median cost for patients who did not experience a bleed, leak, or other serious complication was $1908 ($1712, $2739). Mean incremental cost of reinforced stapling compared with standard was $819.60/surgery. Net QALY gain with reinforced stapling compared with standard was 0.00002. The resultant incremental cost-effectiveness ratio was $40,553,000/QALY. One-way and probabilistic sensitivity analyses failed to produce a value below $150,000/QALY. CONCLUSIONS Compared with standard stapling, reinforced stapling reduces minor postoperative bleeding but not major bleeding or leaks and is not cost-effective if routinely used in laparoscopic sleeve gastrectomy.
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Affiliation(s)
- Alexandra Highet
- University of Michigan Medical School, Ann Arbor, Michigan
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Emily H Johnson
- University of Michigan Medical School, Ann Arbor, Michigan
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Aaron J Bonham
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - David W Hutton
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
- College of Engineering, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and innovation, University of Michigan, Ann Arbor, Michigan
| | - Shuhao Zhou
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Ameen S Thalji
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Amir A Ghaferi
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
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28
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Raftopoulos Y, Rajkumar S, Davidson E, Papasavas P. Prospective Randomized Comparison of Linear Endostaplers During Laparoscopic Sleeve Gastrectomy. Obes Surg 2022; 32:3472-3480. [PMID: 35974292 DOI: 10.1007/s11695-022-06240-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE The development of Laparoscopic Linear Endostaplers (LLES) is crucial in minimally invasive approaches in bariatric surgery, but there have been very few published studies comparing 6-row LLES in Laparoscopic Sleeve Gastrectomy (LSG). The objective of this study was to compare two 6-row LLES in LSG. METHODS A total of 60 patients were prospectively randomized to undergo LSG with either Medtronic Endo GIA™ Tri-Staple technology (MTS) or AEON ™ Endostapler(Lexington Medical) LLES. The measured parameters included patient demographics, comorbidity indices, LLES and specimen characteristics, postoperative symptoms, hospital stay, and total adverse events (AEs). Intraoperative bleeding was evaluated using five laparoscopic and corresponding endoscopic images of staple line before clip application, compared with a 1-5 Visual Analogue Scale (VAS), assessed by an independent bariatric surgeon who was blinded to the LLES used. Images of all cases were reviewed on the same day to increase test-retest reliability. RESULTS Both groups were similar in patient demographics. Compared to MTS, AEON LLES group had significantly lower bleeding VAS scores in 4/5 laparoscopic images (pre-pyloric: 1.7 ± 0.7 vs. 2.36 ± 0.76, p = 0.0007, mid-sleeve: 1.46 ± 0.62 vs. 1.86 ± 0.68, p = 0.019, proximal sleeve: 1.6 ± 0.77 vs. 2.0 ± 0.83, p = 0.038, gastro-esophageal junction: 1.43 ± 0.67 vs. 1.86 ± 0.77, p = 0.014) and 3/5 endoscopic images (pre-pyloric: 1.56 ± 0.56 vs. 2.36 ± 0.76, p = 0.006, incisura: 1.66 ± 0.54 vs. 2.0 ± 0.52, p = 0.021, mid-sleeve: 1.63 ± 0.49 vs. 2.0 ± 0.45, p = 0.005). There was no statistical difference in other parameters. CONCLUSION Both devices were equally safe and effective in terms of LLES and specimen characteristics, patient symptoms, hospital stay, and AEs. Bleeding VAS scores were significantly lower, favoring the AEON LLES.
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Affiliation(s)
- Yannis Raftopoulos
- Weight Management Program, Holyoke Medical Center, Holyoke, MA, 01040, USA
| | - Shruthi Rajkumar
- Weight Management Program, Holyoke Medical Center, Holyoke, MA, 01040, USA.
| | - Elana Davidson
- Weight Management Program, Holyoke Medical Center, Holyoke, MA, 01040, USA
| | - Pavlos Papasavas
- Medical and Surgical Weight Loss Center, Hartford Hospital, Hartford, CT, 06106, USA
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29
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Aboueisha MA, Freeman M, Allotey JK, Evans L, Caposole MZ, Tatum D, Levy S, Baker JW, Galvani C. Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database. Surg Endosc 2022; 37:3090-3102. [PMID: 35927350 DOI: 10.1007/s00464-022-09452-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vertical sleeve gastrectomy (VSG) has demonstrated to be safe; however, controversy remains on how to decrease major complications, particularly bleeding and leaks. There are variations in staple-line reinforcement techniques, including no reinforcement, oversewing, and buttressing. We sought to evaluate the effect of those methods on post-operative complications using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSAQIP) database. METHODS The MBSAQIP was queried for patients who underwent VSG during 2015-2019. A propensity-matched analysis was performed between different staple-line reinforcement (SLR) methods, specifically No reinforcement (NR), Oversewing (OS), and Buttressing (BR). The primary outcome of interest was complications within 30 days. RESULTS A total of 513,354 VSG cases were analyzed. The cohort was majority female (79.0%), with mean (SD) age of 44.2 ± 11.9 years and mean BMI of 45 ± 7.8 kg/m2. Frequency of SLR methods used was 54%BR, 25.6%NR, 10.8% BR + OS, and 9.8%OS. There were no differences in rate of leaks among SLR methods. Compared to NR, BR was associated with decreased rate of reoperations, overall bleeding, and major bleeding (p < 0.05) but prolonged operative time and length of stay (LOS) (p < 0.05). OS was associated with decreased overall bleeding (p < 0.05) but prolonged operative times and length of stay (p < 0.05) compared to NR. Compared to BR, OS was associated with increased operative times, LOS, and rates of post-operative ventilator use, pneumonia, and venous thrombosis (p < 0.05). Patients with bleeding were associated with lower rate of BR (56% vs 61%) and higher rate of NR (34% vs 28%) compared to patients with no bleeding. Bleeding was associated with a greater frequency of leaks (4.4% vs 0.3%), along with higher morbidity and mortality (p < 0.05). CONCLUSIONS Of the reinforcement methods evaluated, BR and OS were both associated with decreased bleeding despite longer operative times. No method was found to significantly reduce incidence of leaks; however, bleeding was associated with increased incidence of leaks, morbidity, and mortality. The liberal use of SLR techniques is recommended for further optimization of patient outcomes after VSG.
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Affiliation(s)
- Mohamed A Aboueisha
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Meredith Freeman
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Jonathan K Allotey
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Leah Evans
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Michael Z Caposole
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Danielle Tatum
- Department of Surgery, Tulane University, New Orleans, LA, 70112, USA
| | - Shauna Levy
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - John W Baker
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Carlos Galvani
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA.
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Value in acute care surgery, part 2: Defining and measuring quality outcomes. J Trauma Acute Care Surg 2022; 93:e30-e39. [PMID: 35393377 DOI: 10.1097/ta.0000000000003638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.
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Iannelli A, Chierici A, Castaldi A, Drai C, Schneck AS. Bioabsorbable Glycolide Copolymer is Effective in Reducing Staple Line Bleeding in Sleeve Gastrectomy. Obes Surg 2022; 32:2605-2610. [PMID: 35696051 DOI: 10.1007/s11695-022-06152-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative bleeding from the staple line after sleeve gastrectomy occurs in 2-8% of patients and it is associated with increased length and cost of hospitalization and may demand reoperation to gain hemostasis. Reinforced staplers are used by bariatric surgeons to reduce the incidence of postoperative leak but can have a role in avoiding bleeding. The aim of this study is to analyze the effects of reinforcement on the whole gastric staple line during sleeve gastrectomy on postoperative bleeding. METHODS Four hundred forty-eight consecutive patients undergoing sleeve gastrectomy from November 2012 to April 2019 were divided into two groups. In the Top-only group only the top staple shot was realized with reinforced material (GORE® SEAMGUARD®) while in the Bottom-to-Top group, patients received full staple line reinforcement. Statistical analysis focused on postoperative leak and bleeding, and length of stay; a propensity score matching analysis was performed to reduce between-group characteristics imbalance. RESULTS One hundred forty-five (Top-only) and 303 (Bottom-to-Top) patients were included. Four (2.8%) patients in the Top-only group and none in the Bottom-to-Top group experienced severe bleeding (p = 0.004); the difference was still significant after propensity score matching. Length of stay was significantly shorter for the Bottom-to-Top group before and after propensity score matching (4 vs. 5 days, p < 0.001). CONCLUSIONS Staple line buttressing reduces the incidence of severe postoperative bleeding when performed on the whole staple line, and it is associated with a shorter hospitalization.
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Affiliation(s)
- Antonio Iannelli
- Université Côte d'Azur, Nice, France.
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, France.
- Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France.
| | - Andrea Chierici
- Service de Chirurgie Digestive, Centre Hospitalier d'Antibes Juan-Les-Pins, 107, av. de Nice, 06600, Antibes, France
| | - Antonio Castaldi
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, France
| | - Céline Drai
- Université Côte d'Azur, Nice, France
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, France
| | - Anne-Sophie Schneck
- Digestive Surgery Unit, Centre Hospitalier Universitaire de Guadeloupe, 97159, Pointe à Pitre, Guadeloupe
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Di Capua F, Cesana GC, Uccelli M, Ciccarese F, Olmi S. Comparison of Laparoscopic Sleeve Gastrectomy Bleeding and Leakage Rates in Four Staple-Line Reinforcement Methods: A Prospective Observational Study. J Laparoendosc Adv Surg Tech A 2022; 32:1176-1180. [PMID: 35467939 DOI: 10.1089/lap.2022.0122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Staple-line bleeding and gastric leakage are the most serious complications of laparoscopic sleeve gastrectomy (LSG). Reinforcement of the staple line is reported to be a method to reduce these complications rates, but the question of which method is preferable is a matter of controversy in the literature. In this study, we compared different staple-line reinforcement methods to assess their efficiency in preventing staple-line bleeding and leakage. Materials and Methods: Two hundred patients eligible for LSG were enrolled in the study and randomized into five groups based on the reinforcement method used during surgery: no reinforcement, oversewing using 3-0 polydioxanone (PDS) suture, oversewing using 4-0 barbed absorbable closure device (V-Lock), fibrin sealant glue, and buttress material. Intraoperative and postoperative complications were recorded and analyzed. Differences were considered statistically significant for P < .05. Results: The no-reinforcement group showed higher bleeding rates (20%), although only 2.5% of the patients required reintervention. All groups using staple-line reinforcement showed better outcomes in bleeding rates (P < .05). No statistically significant differences were observed among the groups in terms of the leakage rate, reintervention rate, intraoperative complications, and operative times. Conclusion: The reinforcement of the staple line decreased the bleeding rate in sleeve gastrectomy but did not affect the gastric leakage rate.
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Affiliation(s)
- Francesco Di Capua
- Department of General and Oncologic Surgery, Centre of Advanced Laparoscopic Surgery, Centre of Bariatric Surgery-San Marco Hospital GSD, Zingonia, Italy
| | - Giovanni Carlo Cesana
- Department of General and Oncologic Surgery, Centre of Advanced Laparoscopic Surgery, Centre of Bariatric Surgery-San Marco Hospital GSD, Zingonia, Italy
| | - Matteo Uccelli
- Department of General and Oncologic Surgery, Centre of Advanced Laparoscopic Surgery, Centre of Bariatric Surgery-San Marco Hospital GSD, Zingonia, Italy
| | - Francesca Ciccarese
- Department of General and Oncologic Surgery, Centre of Advanced Laparoscopic Surgery, Centre of Bariatric Surgery-San Marco Hospital GSD, Zingonia, Italy
| | - Stefano Olmi
- Department of General and Oncologic Surgery, Centre of Advanced Laparoscopic Surgery, Centre of Bariatric Surgery-San Marco Hospital GSD, Zingonia, Italy
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Kiriakopoulos A, Kounatidis N, Menenakos I, Kostrova M, Zografos K, Menenakos E. Non-stenting treatment versus endoscopic stent placement in staple line leaks after laparoscopic sleeve gastrectomy. Langenbecks Arch Surg 2022; 407:1863-1872. [PMID: 35333965 DOI: 10.1007/s00423-022-02498-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Presentation of results of non-stenting treatment versus endoscopic stenting placement in gastric staple leaks after laparoscopic sleeve gastrectomy (LSG). METHODS Between January 2007 and August 2020, 1371 eligible patients underwent LSG. After gastric leak detection, patients were classified into treatment groups A (endoscopic stent placement) and B (non-stenting management). Overall hospital stay, the time to complete gastric leak resolution and the incidence of further operative management constituted the main outcome measures. Statistical analysis included descriptive statistics and linear regression tests as needed. RESULTS A total of 27 patients (19 F/8 M, median age: 44.8 years (range: 36-58) with median preoperative BMI: 43.5 kg/m2 (range: 37.0-48.7)) presented with gastric staple line leak (1.9%) - mean detection day 5.8 postop (range: 1-12). Eight patients enrolled in group A and 19 patients in group B. The mean hospital stay for group A was 41.2 days (range: 24-60) versus 15 days (range: 12-18) for group B (p < 0.001). Complete leakage resolution was observed at mean 42.4 days (range 25-60) for group A and 34.5 days (range: 28-40) for group B patients, (p = 0.025). Only 2 group A patients accomplished complete leak resolution without additional intervention. Five group A patients (62.5%) versus 4 group B patients (21.1%) needed operative intervention during the treatment course (p = 0.037). CONCLUSIONS Conservative, non-stenting treatment of staple line leaks after LSG is feasible and is associated with superior results in terms of hospital say and leak resolution in comparison to endoscopic stenting.
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Affiliation(s)
- Andreas Kiriakopoulos
- 5th Surgical Clinic, "Evgenideion Hospital", National and Kapodistrian University of Athens School of Medicine, Papadiamantopoulou 20 Str., PO: 11528, Athens, Greece.
| | - Nefeli Kounatidis
- 5th Surgical Clinic, "Evgenideion Hospital", National and Kapodistrian University of Athens School of Medicine, Papadiamantopoulou 20 Str., PO: 11528, Athens, Greece
| | - Ilias Menenakos
- Actuarial Science, Department of Statistics, London School of Economics, London, UK
| | - Maria Kostrova
- Actuarial Science, Department of Statistics, London School of Economics, London, UK
| | - Konstantinos Zografos
- 5th Surgical Clinic, "Evgenideion Hospital", National and Kapodistrian University of Athens School of Medicine, Papadiamantopoulou 20 Str., PO: 11528, Athens, Greece
| | - Evangelos Menenakos
- 5th Surgical Clinic, "Evgenideion Hospital", National and Kapodistrian University of Athens School of Medicine, Papadiamantopoulou 20 Str., PO: 11528, Athens, Greece.,1st Clinic, Division of Morbid Obesity and Metabolic Surgery, "Ippokrateion Hospital", National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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34
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Antrum Preservation Versus Antrum Resection in Laparoscopic Sleeve Gastrectomy With Effects on Gastric Emptying, Body Mass Index, and Type II Diabetes Remission in Diabetic Patients With Body Mass Index 30-40 kg/m 2: a Randomized Controlled Study. Obes Surg 2022; 32:1412-1420. [PMID: 35304705 PMCID: PMC8986727 DOI: 10.1007/s11695-022-05982-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 02/07/2023]
Abstract
Background Laparoscopic sleeve gastrectomy (LSG) is a widely performed procedure nowadays. There is a controversy on whether antrum resection (AR) or antrum preservation (AP) should be done and if this has an effect on BMI, gastric emptying, and associated medical conditions such as diabetes mellitus (DM). Study Design This randomized controlled trial included 56 patients in the AP group and 53 patients in the AR group with BMI 30–40 kg/m2. Weight, BMI, fasting and postprandial blood glucose (FBS and PPBS), HbA1C, oral hypoglycemic drug use, and % gastric emptying by gastric scintigraphy at 30, 60, 90, and 120 min were recorded preoperatively and postoperatively at 3, 6, and 12 months. Postoperative % of total weight loss (TWL) and symptoms of de novo GERD were observed at 3, 6, and 12 months. Results The AR group had significantly lower BMI and HbA1C and higher %TWL than the AP group. There was a significant difference between the two groups regarding % of gastric emptying with the AP group showing higher values at 30, 60, 90, and 120 min. There were no significant differences regarding FBS, PPBS, and oral hypoglycemic use. The AR group had more incidence of GERD symptoms postoperatively yet with no significant difference. Conclusion LSG with antrum resection (2 cm from the pylorus) had significantly less postoperative BMI, higher %TWL, better control of type II DM, and more retention of gastric contents in patients with BMI 30–40 kg/m2 in comparison with LSG with antral preservation with non-significant increase in incidence of GERD symptoms. Graphical abstract ![]()
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Kermansaravi M, Shahmiri SS, Khalaj A, Jalali SM, Amini M, Alamdari NM, Mahmoudieh M, Jangjoo A, Abbas SI, Naeini SMM, Sayadishahraki M, Eghbali F, Mirhashemi SH, Mokhber S, Jazi AD, Pazouki A. The First Web-Based Iranian National Obesity and Metabolic Surgery Database (INOSD). Obes Surg 2022; 32:2083-2086. [PMID: 35303260 DOI: 10.1007/s11695-022-06014-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Mohammad Kermansaravi
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. .,Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat_e Rasool Hospital, Tehran, Iran.
| | - Shahab Shahabi Shahmiri
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.,Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat_e Rasool Hospital, Tehran, Iran
| | - Alireza Khalaj
- Tehran Obesity Treatment Center, Department of Surgery, Shahed University, Tehran, Iran
| | - Seyed Mehdi Jalali
- Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Amini
- Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nasser Malekpour Alamdari
- Critical Care Quality Improvement Research Center at Shahid Modarres Hospital, Department of General Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Mahmoudieh
- Department of Surgery, Isfahan Minimally Invasive Surgery and Obesity Research Center, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Jangjoo
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | | | - Masoud Sayadishahraki
- Department of Surgery, Isfahan Minimally Invasive Surgery and Obesity Research Center, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Foolad Eghbali
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.,Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat_e Rasool Hospital, Tehran, Iran
| | - Seyed Hadi Mirhashemi
- Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayyeh Mokhber
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Davarpanah Jazi
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran.,Department of General Surgery, Shariati Hospital, Isfahan, Iran
| | - Abdolreza Pazouki
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.,Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat_e Rasool Hospital, Tehran, Iran
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36
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Suture or Not Suture: is Staple Line Reinforcement Necessary in Laparoscopic Sleeve Gastrectomy? Obes Surg 2022; 32:2463-2464. [DOI: 10.1007/s11695-022-06009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
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Martines G, Tomasicchio G, Picciariello A, Dibra R, Trigiante G, Lantone G, Altomare DF. Staple line reinforcement with nebulized cyanoacrylate glue in laparoscopic sleeve gastrectomy: A propensity score-matched study. Open Med (Wars) 2022; 17:197-204. [PMID: 35111973 PMCID: PMC8772997 DOI: 10.1515/med-2022-0426] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 12/29/2022] Open
Abstract
Background A dreaded complication of laparoscopic sleeve gastrectomy (LSG) is suture leak. The study aimed to assess the efficacy of the nebulized comonomer Glubran 2® (N-butyl-cyanoacrylate + metacrylosysolfolane) applied to the LSG staple line. Methods A propensity-matched comparison analysis was conducted in 125 patients undergoing LSG between 2017 and 2019. Groups included those treated with Glubran® (group 1, n = 70) and those without Glubran® treatment (group 2, n = 55). Results There were differences in the mean body mass index (44.4 vs 43 kg/m2; P < 0.05) between the groups. There was a non-significant increase in the operative time for group 1 compared with group 2 (97 ± 8 vs 93.8 ± 10.7 min; P = 0.07), with a greater amount of estimated blood loss (94.5 mL vs 87.8; P < 0.01). There were more severe complications in group 2 over group 1 cases (8 vs 0%; P < 0.05), although postoperative bleeding did not differ between the two groups (1.4 vs 5.4%). There were no postoperative leaks in group 1 patients, but there were two leaks in group 2 cases with an increased length of hospital stay in patients with a leak. Conclusion Glubran® LSG support may reduce leak risk without increasing operating time.
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Affiliation(s)
- Gennaro Martines
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Giovanni Tomasicchio
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Arcangelo Picciariello
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Rigers Dibra
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Giuseppe Trigiante
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Giuliano Lantone
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Donato Francesco Altomare
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
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Ferraz ÁAB, Santa-Cruz F, Belfort JV, Sá VCT, Siqueira LT, Araújo-Júnior JGC. THE ROUTINE USE OF THE METHYLENE BLUE TEST IN SLEEVE GASTRECTOMY: WHY NOT? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2022; 34:e1612. [PMID: 35019124 PMCID: PMC8735257 DOI: 10.1590/0102-672020210002e1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/29/2021] [Indexed: 11/22/2022]
Abstract
Background:
Although considered a safe procedure, sleeve gastrectomy (SG) has a non-negligible risk of major postoperative complications related to it, with special attention to gastric leaks.
Aim:
Evaluate the clinical value of the methylene blue test (MBT) in predicting the occurrence of post-SG leaks.
Methods: Retrospective study that included 1136 patients who underwent SG with intraoperative MBT between 2012 and 2016. Sensitivity, specificity, positive predictive value (PPV) and negative predicted value (NPV) were calculated to determine the clinical correlation between the MBT and the occurrence of postoperative leaks. Staple line oversewing was performed in all patients who presented positive MBT.
Results:
Laparoscopic SG was performed in 97.0% of cases; open in 2.3%, and robotic in 0.7%. MBT was positive in 19 cases (1.67%). One positive MBT occurred during an open SG and the other 18 at laparoscopy. Moreover, there were nine cases (0.8%) of postoperative leaks, among which, only two presented positive MBT. MBT diagnostic value was evaluated through the calculation of sensitivity (22.0%), specificity (98.0%), PPV (11.0%) and NPV (99.0%). There were no cases of allergic reaction or any other side effect with the use of the methylene blue solution.
Conclusion:
MBT showed high specificity and negative predictive value, thus presenting an important value to rule out the occurrence of postoperative leaks.
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Affiliation(s)
- Álvaro A B Ferraz
- Department of Surgery, Hospital de Clínicas, Federal University of Pernambuco, Recife, PE, Brazil.,Gastrointestinal Surgery Service, Esperança Hospital, Rede D'Or São Luiz, Recife, PE, Brazil
| | | | | | - Vladimir C T Sá
- General Surgery Service, Hospital Agamenon Magalhães, Recife, PE, Brazil
| | - Luciana T Siqueira
- Department of Surgery, Hospital de Clínicas, Federal University of Pernambuco, Recife, PE, Brazil
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Mou D, Tavakkoli A. Surgical Management of Obesity. NUTRITION, WEIGHT, AND DIGESTIVE HEALTH 2022:257-267. [DOI: 10.1007/978-3-030-94953-2_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Salyer CE, Thompson J, Hanseman D, Diwan T, Watkins BM, Kuethe J, Goodman MD. Surprising neutral effect of shorter staple cartridges in laparoscopic sleeve gastrectomy. Surg Endosc 2021; 36:5049-5054. [PMID: 34767062 DOI: 10.1007/s00464-021-08865-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Consensus agreements regarding laparoscopic sleeve gastrectomy (LSG) advise against using staple loads less than 1.5 mm in closed staple height. However, few data exist to support this recommendation. We hypothesized that using staples with a shorter closed height would actually decrease incidence of intraoperative and postoperative bleeding during LSG, while not increasing the incidence of leak. METHODS All LSG cases for a single institution from 1/1/2014 to 12/31/2019 were exported for analysis. Two cohorts were established: 1. 'Green/Blue' group was cases in which no white cartridges were used and 2. 'White' group was cases in which any white cartridges were used. Demographic variables, procedural characteristics, hospital length of stay, and postoperative outcomes were compared between groups. RESULTS The study populations included 1710 patients, 974 in the green/blue group and 736 in the white cartridge group. There were no significant differences in postoperative leak, bleed, stricture, readmission, or death while using white staple loads as compared with the standard combination of blue and green loads. CONCLUSION Using staples with a shorter closed height during LSG did not impact the postoperative bleeding or leak rate. The impact from selection of shorter staples to achieve more tissue compression may be limited.
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Affiliation(s)
- Christen E Salyer
- Division of Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jonathan Thompson
- Section of General Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA.,Standard Bariatrics, Inc., Cincinnati, OH, USA
| | - Dennis Hanseman
- Division of Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Tayyab Diwan
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | - Joshua Kuethe
- University of Colorado Department of Surgery, Aurora, CO, USA
| | - Michael D Goodman
- Division of Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA. .,Division of Research, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267-0558, USA.
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41
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Feng XC, Burch M. Management of Postoperative Complications Following Bariatric and Metabolic Procedures. Surg Clin North Am 2021; 101:731-753. [PMID: 34537140 DOI: 10.1016/j.suc.2021.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.
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Affiliation(s)
- Xiaoxi Chelsea Feng
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA
| | - Miguel Burch
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA.
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Gjeorgjievski M, Imam Z, Cappell MS, Jamil LH, Kahaleh M. A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks. J Clin Gastroenterol 2021; 55:551-576. [PMID: 33234879 DOI: 10.1097/mcg.0000000000001451] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus. OBJECTIVE To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed. DESIGN A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes. RESULTS Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise. CONCLUSION Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
| | - Zaid Imam
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Mitchell S Cappell
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Laith H Jamil
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
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Li M, Zeng N, Liu Y, Yan W, Zhang S, Wu L, Liu S, Wang J, Zhao X, Han J, Kang J, Zhang N, Zhang P, Bai R, Zhang Z. The Choice of Gastric Bypass or Sleeve Gastrectomy for Patients Stratified by Diabetes Duration and Body Mass Index (BMI) level: Results from a National Registry and Meta-analysis. Obes Surg 2021; 31:3975-3989. [PMID: 34132996 DOI: 10.1007/s11695-021-05459-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE To determine whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) should be the optimal choice in patients stratified by diabetes duration and body mass index (BMI) level. METHODS Classification tree analysis was performed to identify the influential factors for surgical procedure selection in real setting. Meta-analyses stratified by influential factors were conducted to compare the complete diabetes remission rates between SG and RYGB. The cost-effectiveness analysis was performed when results from meta-analysis remain uncertain. RESULTS Among 3198 bariatric procedures in China, 824 (73%) SGs and 191 (17%) RYGBs were performed in patients with T2DM. Diabetes duration with a cutoff value of 5 years and BMI level with 35.5 kg/m2 were identified as the influential factors. For patients with diabetes duration > 5 years, RYGB showed a significant higher complete diabetes remission rate than SG at 1 year: 0.52 (95% confidence interval (CI): 0.46-0.58) versus 0.36 (95% CI: 0.30-0.42). For patients with diabetes duration ≤ 5 years and BMI ≥ 35.5 kg/m2, there was no significant difference between 2 procedures: 0.57 (95% CI: 0.43-0.71) for SG versus 0.66 (95% CI: 0.62-0.70) for RYGB. The cost-effectiveness ratios of SG and RYGB were 244.58 and 276.97 dollars per QALY, respectively. CONCLUSIONS For patients with diabetes duration > 5 years, RYGB was the optimal choice with regard to achieving complete diabetes remission at 1 year after surgery. However, for patients with diabetes duration ≤ 5 years and BMI ≥ 35.5 kg/m2, SG appeared to provide a cost-effective choice.
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Affiliation(s)
- Mengyi Li
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, No.95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Na Zeng
- National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Yang Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, No.95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Wenmao Yan
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, South West Ring Road, Fengtai District, Beijing, 100070, China
| | - Songhai Zhang
- Department of Metabolic and Bariatric Surgery, Xinxiang Second People's Hospital, No.389 Middle Section of Hongli Avenue, Muye District, Xinxiang, 453002, Henan Province, China
| | - Liangping Wu
- Jinshazhou Hospital of Guangzhou University of Chinese Medicine, No.1 Li-Chuan East Street, Baiyun District, Guangzhou, 510168, Guangdong Province, China
| | - Shaozhuang Liu
- Department of Metabolic and Bariatric Surgery, Department of General Surgery, Qilu Hospital of Shandong University, No.107 Cultural West Road, Jinan, 250012, Shandong Province, China
| | - Jun Wang
- Department of Gastrointestinal Surgery, Tangshan Gongren Hospital, No.27 Cultural Road, Lubei District, Tangshan, 063000, Hebei Province, China
| | - Xiangwen Zhao
- Department of Metabolic and Bariatric Surgery, Xiaolan People's Hospital of Zhongshan, No.65 Middle Section of Jucheng Avenue, Zhongshan, 528415, Guangdong Province, China
| | - Jianli Han
- Department of General Surgery, Bethune Hospital of Shanxi, No.99 Longcheng Street, Xiaodian District, Taiyuan, 030032, Shanxi Province, China
| | - Jiansheng Kang
- Department of General Surgery, The Second Hospital of Hebei Medical University, No.215 Heping West Road, Shijiazhuang, 050000, Hebei Province, China
| | - Nengwei Zhang
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University/Peking University, Ninth Clinical Medical College, Tieyilu 10, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Peng Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, No.95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China.
| | - Rixing Bai
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, South West Ring Road, Fengtai District, Beijing, 100070, China.
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, No.95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China.
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Derebey M, Tarim IA, Mutlu V, Ozbalci AB, Ozbalci GS. Modified Omentopexy in Laparoscopic Sleeve Gastrectomy: Does It Reduce the Risk of Postoperative Complications? Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2020.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Murat Derebey
- Department of General Surgery and Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ismail Alper Tarim
- Department of General Surgery and Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Vahit Mutlu
- Department of General Surgery and Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Aysu Basak Ozbalci
- Department of Radiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Gokhan Selcuk Ozbalci
- Department of General Surgery and Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Remodifying Omentopexy Technique Used with Laparoscopic Sleeve Gastrectomy: Does It Change any Outcomes? Obes Surg 2021; 30:1527-1535. [PMID: 31989384 DOI: 10.1007/s11695-019-04357-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Gastric obstructions, leaks and staple line bleeding are reported after laparoscopic sleeve gastrectomy (LSG). There is no ideal method or technique to avoid these mishaps. We added modified omentopexy (OP) to LSG to determine if there is any effect on gastric leaks and some other complications. METHODS This single institution case control study included two groups of morbidly obese patients undergoing LSG. They were grouped as omentopexy (OP) or no omentopexy (NP). Patient characteristics such as age, sex, ASA (American Society of Anesthesiologists) risk, body mass index (BMI), nutritional status and comorbidities were comparable. Postoperative follow-up was scheduled at 1 week, 1 month, 3 months, 6 months and 12 months. All received standard postoperative clinical, nutritional evaluation and PPI therapy for at least 3 months. RESULTS Total 737 patients underwent LSG from January 2012 to December 2017. Out of these, 370 that had OP and 367 that had NP were analyzed. NP group was subdivided into Lemberted Staple line (LS) and bioabsorbable staple line reinforcement (BSLR) groups. Gastric leaks and perforations were clubbed together as gastric disruptions (GD). Patients with at least 15 months of postoperative follow-up were included. Those who failed to follow up were excluded. GD was reported in 7 out of 367 NP patients (1.9%), while no GD was seen in 370 OP patients (P = 0.01). Bleeding was seen in 1 OP versus 2 NP patients (P = 0.6). Venous thromboembolism was reported in 2 OP versus 1 NP patients (P = 1). Wound infection was seen in 1 OP versus 2 NP patients (P = 0.6). Readmissions were noted in 2 OP versus 6 NP patients (P = 0.1). Pneumonia was seen in 2 OP and 2 NP patients (P = 1). Postoperative dehydration was seen in zero OP versus 1 NP patients (P = 0.4). Gastric obstruction was not seen in any of the patients. Postoperative gastric reflux was present in 49/370(13.2%) OP versus 57/367(15.4%) NP patients (P = 0.4). Within NP group, LS (Lemberting of Staple line) patients (286/367) had 4 GD (1.39%) versus no GD in OP (P = 0.03). BSLR (Bioabsorbable Staple line re-enforcement) patients (81/367) had 3 GD (3.7%) versus no GD in OP (P = 0.005). None of the groups had any mortality. CONCLUSIONS GD (gastric disruptions) were statistically significant, but the following bleeding, venous thromboembolism and gastroesophageal reflux did not reach statistical significance, which indicates that OP, if performed correctly with LSG, has favorable effects on gastric leaks.
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46
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Evaluating the Effect of Surgical Skill on Outcomes for Laparoscopic Sleeve Gastrectomy: A Video-based Study. Ann Surg 2021; 273:766-771. [PMID: 31188214 DOI: 10.1097/sla.0000000000003385] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prior studies have demonstrated a correlation between surgical skill and complication rates after laparoscopic Roux-en-Y gastric bypass. However, the impact of surgical skill on a similar but less technically challenging procedure such as sleeve gastrectomy (SG) is unknown. METHODS Practicing bariatric surgeons (n = 25) participating in a statewide quality improvement collaborative submitted an unedited deidentified video of a representative laparoscopic SG. Videos were obtained between 2015 and 2016 and were rated by bariatric surgeons in a blinded fashion using a validated instrument that assesses surgical skill. Overall scores were based on a 5-point Likert scale with 5 representing a "master surgeon" and 1 representing a "surgeon-in-training." Risk-adjusted 30-day complication rates, 1-year weight loss among cases performed during the study period, and operative technique were compared between surgeons rated in the top and bottom quartiles according to skill. RESULTS Surgeon ratings for skill varied between 2.73 and 4.60. Ratings for skill did not correlate with overall 30-day risk-adjusted complication rates (Pearson correlation coefficient, 0.213, P = 0.303). However, surgeons with higher skill ratings had lower rates of specific surgical complications, including postoperative obstruction (0.13% vs 0.3%, P = 0.017), hemorrhage (0.85% vs 1.27%, P = 0.005), and reoperation (0.24% vs 0.92%, P < 0.0001). Surgeons ranked in the top quartile for skill had faster operating times for SG (59.0 vs 82.1 min, P < 0.0001) and higher annual case volumes for both SG and any bariatric procedure (224.3 cases/yr vs 73.4 cases/yr, P = 0.009 and 244.9 cases/yr and 93.9 cases/yr, P = 0.009) when compared with surgeons in the bottom quartile. When comparing operative technique, top rated surgeons were noted to have a higher likelihood of using buttressing (83.3% vs 0%, P = 0.0041) and intraoperative endoscopy (83.3% vs 0%, P = 0.0041). CONCLUSIONS Peer ratings for surgical skill varied for laparoscopic sleeve gastrectomy but did not have a significant impact on overall complication rates. Top rated surgeons had lower rates of obstruction, hemorrhage, and reoperation; however, severe morbidity remained extremely low among all surgeons.
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Abstract
Bariatric surgery has emerged as the most effective means of achieving weight loss. Obesity surgery is a quickly expanding field. Laparoscopic vertical sleeve gastrectomy is a great option for patients because it is simple, exceedingly safe, has a fairly defined postoperative complication profile, and is as effective as more complex bariatric surgery options. Specific consideration of patients' comorbidities, assessment of surgeon's skill, and knowledge of preoperative, perioperative, and postoperative course is a must for all surgeons who wish to perform this procedure. If properly used, vertical sleeve gastrectomy is a powerful tool in combating obesity and its deleterious effects.
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Perioperative Practices Concerning Sleeve Gastrectomy - a Survey of 863 Surgeons with a Cumulative Experience of 520,230 Procedures. Obes Surg 2021; 30:483-492. [PMID: 31677017 DOI: 10.1007/s11695-019-04195-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sleeve Gastrectomy (SG) is the most commonly performed bariatric procedure worldwide. There is currently no scientific study aimed at understanding variations in practices concerning this procedure. The aim of this study was to study the global variations in perioperative practices concerning SG. METHODS A 37-item questionnaire-based survey was conducted to capture the perioperative practices of the global community of bariatric surgeons. Data were analyzed using descriptive statistics. RESULTS Response of 863 bariatric surgeons from 67 countries with a cumulative experience of 520,230 SGs were recorded. A total of 689 (80%) and 764 (89%) surgeons listed 13 absolute and relative contraindications, respectively. 65% (n = 559) surgeons perform routine preoperative endoscopy and 97% (n = 835) routinely use intraoperative orogastric tube for sizing the resection. A wide variation is observed in the diameter of the tube used. 73% (n = 627) surgeons start dividing the stomach at a distance of 3-5 cm from the pylorus, and 54% (n = 467) routinely use staple line reinforcement. Majority (65%, n = 565) of surgeons perform routine intraoperative leak test at the end of the procedure, while 25% (n = 218) surgeons perform a routine contrast study in the early postoperative period. Lifelong multivitamin/mineral, iron, vitamin D, calcium, and vitamin B12 supplementation is advocated by 66%, 29%, 40%, 38% and 44% surgeons, respectively. CONCLUSION There is a considerable variation in the perioperative practices concerning SG. Data can help in identifying areas for future consensus building and more focussed studies.
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Edgerton C, Heshmati K, Herman A, Dey T, Dehkharghani R, Ramsis R, Robinson M, Vernon A, Ghushe N, Spector D, Shikora S, Tavakkoli A, Sheu EG. Fellowship training influences learning curves for laparoscopic sleeve gastrectomy. Surg Endosc 2021; 36:1601-1608. [PMID: 33620566 DOI: 10.1007/s00464-021-08372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgical procedure. Little is known about how surgeon training background influences the learning curve of this procedure. We examined operating times (OT), weight loss outcomes, and 30-day complications between surgeons with and without fellowship training in LSG. We hypothesize that post-residency training specific to LSG influences learning curves. METHODS Surgeons from a single institution were split into two groups: those who had not completed fellowship training in LSG (NF, n = 3), and those who had completed LSG specific training in fellowship (SGF, n = 3). OTs, BMI changes at 1 year, and 30-day readmissions, reoperations, and complications were extracted for the first 100 LSG cases of each surgeon. Data were analyzed in bins of 20 cases. Comparisons were made between cohorts within a bin and between adjacent bins of the same surgeon cohort. Logistic regression analyses were performed of OT and weight loss outcomes. RESULTS SGF surgeons showed no difference in OTs over their first 100 cases. NF surgeons had statistically significant increased OTs compared to SGF surgeons during their first 60 cases and progressively shortened OTs during that interval (109 min to 78 min, p < 0.001 for NF surgeons vs. 73 min to 69 min, SGF surgeons). NF surgeons had a significantly steeper slope for improvement in OT over case number. There was no correlation between case number and weight loss outcomes in either group, and no differences in 30-day outcomes between groups. CONCLUSION Surgeons who trained to perform LSG in fellowship demonstrate faster and consistent OR times on their initial independent LSG cases compared to surgeons who did not, with no correlation between case number and weight loss outcomes or safety profiles for either group. This suggests that learning curves for LSG are achieved during formal case-specific fellowship training.
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Affiliation(s)
- Colston Edgerton
- Division of Gastrointestinal Surgery, Center for Metabolic and Bariatric Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Keyvan Heshmati
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ashley Herman
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Tanujit Dey
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Robab Dehkharghani
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ramsis Ramsis
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Malcolm Robinson
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ashley Vernon
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Neil Ghushe
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - David Spector
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Scott Shikora
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ali Tavakkoli
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Eric G Sheu
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA. .,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Chhabra KR, Thumma JR, Varban OA, Dimick JB. Associations Between Video Evaluations of Surgical Technique and Outcomes of Laparoscopic Sleeve Gastrectomy. JAMA Surg 2021; 156:e205532. [PMID: 33325998 DOI: 10.1001/jamasurg.2020.5532] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance In any surgical procedure, various aspects of technique may affect patient outcomes. As new procedures enter practice, it is difficult to evaluate the association of each aspect of technique with patient outcomes. Objective To examine the associations between technique and outcomes in laparoscopic sleeve gastrectomy. Design, Setting, and Participants In this cohort study of bariatric surgery programs participating in a statewide surgical quality improvement collaborative, 30 surgeons submitted intraoperative videos from representative sleeve gastrectomies performed on 6915 patients with morbid obesity. These videos were reviewed by blinded peer surgeons on key technical elements, and 605 reviews were linked to sleeve gastrectomy outcomes of all of the surgeons' patients from January 1, 2015, to December 31, 2016. Exposures Surgeons' technical approaches to 5 controversial aspects of laparoscopic sleeve gastrectomy: dissection of the proximal stomach, sleeve caliber, sleeve anatomy, staple line reinforcement, and leak testing. Main Outcomes and Measures The 30-day outcomes were rate of postoperative hemorrhage and staple line leak. The 1-year outcomes were percentage of total weight lost and reflux severity (Gastroesophageal Reflux Disease Health-Related Quality of Life instrument). Results A total of 30 surgeons submitted 46 videos of operations performed on 6915 patients (mean [SD] age, 45.4 [11.7] years; 5494 [79.5%] female; 4706 [68.1%] White). Complete dissection of the proximal stomach was associated with reduced hemorrhage rates (higher ratings for complete mobilization of fundus were associated with a decrease in hemorrhage rate from 2.1% [25th percentile] to 1.0% [75th percentile], P = .01; higher ratings for visualization of the left crus were associated with a decrease in hemorrhage rate from 1.5% to 0.94%, P = .006; and higher ratings for complete division of the short gastrics were associated with a decrease in hemorrhage rate from 2.8% to 1.2%, P = .03). The reduction in hemorrhage rates came at the expense of higher leak rates (higher ratings for complete mobilization of fundus were associated with an increase in leak rate from 0.05% [25th percentile] to 0.16% [75th percentile], P < .001; higher ratings for visualization of the left crus were associated with an increase in leak rate from 0.1% to 0.2%, P = .003; and higher ratings for complete division of the short gastrics were associated with an increase in leak rate from 0.02% to 0.1%, P = .01). Surgeons who stapled more tightly to the bougie had smaller decreases in reflux than those who stapled less tightly (-2.0 to -1.3 on a 50-point scale, P = .002). Staple line reinforcement (buttressing and oversewing) was associated with a small (2 of 1000 cases) decrease in hemorrhage rates. Staple line buttressing was also associated with a similarly small increase in leak rates (1 of 1000 cases). Leak testing was associated with a statistically insignificant change in the staple line leak rate (0.16%-0.22%, P = .47). Conclusions and Relevance Variations in surgical technique can be measured by video review and are associated with differences in patient outcomes.
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Affiliation(s)
- Karan R Chhabra
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Oliver A Varban
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor.,Section Editor, JAMA Surgery
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