Understanding the significance, reasons and patterns of abnormal vital signs after gastric bypass for morbid obesity

Continuous monitoring after laparoscopic Roux-En-Y gastric bypass: a pathway to ambulatory care surgery - a pilot study

Same-day discharge (SDD) after Laparoscopic Roux-En-Y Gastric Bypass (LRYGB) faces resistance due to possible undetected postoperative complications. These present with changes in vital signs, which continuous remote monitoring devices can detect. This study compared continuous vital signs monitoring using the Isansys Patient Status Engine™ with standard nursing vital signs measurements to assess the device's reliability in postoperative surveillance of patients undergoing LRYGB. We conducted a pilot study including patients who underwent LRYGB. During their hospital stay, patients were continuously monitored using the Isansys Patient Status Engine™ with Lifetouch™, Lifetemp™, and Nonin Pulse Oximeter™ sensors. The heart rate (HR), body temperature, and oxygen saturation (SpO2) collected by the device were compared with standard nursing assessments. Thirteen patients with a mean body mass index of 41.5 ± 4.4 kg/m2 were included. No major complications occurred. The median HR assessed by standard and continuous monitoring did not significantly differ (75.5 [69-88] vs. 77 [66-91] bpm, p = 0.995), nor did the mean values of SpO2 (94.7 ± 2.0 vs. 93.7 ± 1.8%, p = 0,057). A significant difference was observed in median body temperature between the nursing staff and the monitoring device (36.3 [36.1-36.7] vs. 36.1 [34.5-36.6] degrees Celsius, p = 0.012), with a tendency for lower temperature measurements by the device. In conclusion, this is the first study on continuous postoperative surveillance using the Isansys Patient Status Engine™ monitoring device for LRYGB patients. Our results introduce a novel tool for more efficient surgery. Prospective randomized experimental studies are warranted to evaluate this method's efficacy and safety.

A 10-year experience with anastomotic leaks in upper gastrointestinal surgery-Retrospective cohort study

BACKGROUND

Anastomotic leak (AL) in upper gastrointestinal (UGI) surgery continues to be a diagnostic challenge. We seek to identify clinical parameters that predict AL and examine the effectiveness of investigations in evaluating AL following UGI surgeries.

METHODS

592 patients underwent UGI surgeries with an anastomosis between January 2011 and January 2021. Data on patient characteristics, surgery, postoperative investigations and outcomes were prospectively collected and analysed.

RESULTS

The overall occurrence of AL was 6.4 %. Tachycardia >120 BPM (OR 6.959, 95 % CI 1.856-26.100, p = 0.004) and leukocyte count >19 × 109/L (OR 3.327, 95 % CI 1.009-10.967, p = 0.048) were independent predictors of AL. On multivariate analysis, patients whose anastomosis was deemed high risk and had pre-emptive investigation done postoperatively to exclude a leak were less likely to require intervention and were more likely to be managed conservatively (66.7 % vs 14.3 %, p = 0.025). Methylene blue test, oral contrast study and Computed Tomography scan with intravenous and oral contrast had 50.0 %, 20.0 % and 9.1 % false negative results, while esophagogastroduodenoscopy had none. There was no misdiagnosed AL when more than 1 investigation (n = 15, 39.5 %) were performed.

CONCLUSION

Our study demonstrates that the presence of a triad including desaturation, tachycardia and leucocytosis predicts for AL following UGI surgery and for confirmation of a leak, evaluation with 2 or more investigation is needed. A practice of evaluating high risk anastomosis prior to commencement of feeding decreased the need for surgical intervention and improves success of conservative treatment.

Feasibility of same-day discharge after laparoscopic sleeve gastrectomy in the Netherlands

BACKGROUND

There is a trend towards laparoscopic sleeve gastrectomy (SG) with same-day discharge (SDD), as an efficient healthcare pathway to alleviate the burden on clinical capacity. This approach seems to be safe, if patients are carefully selected. In our bariatric center, a protocol for Roux-en-Y gastric bypass with SDD has already been successfully implemented. The aim of this study was to evaluate feasibility of applying the same SDD protocol for SG.

METHODS

A single-center prospective feasibility study was conducted at a high-volume bariatric center. Low-risk patients who were scheduled for primary SG were included. Strict criteria were used for approval upon SDD. The primary outcome was the rate of successful SDD without readmission within 48 h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality.

RESULTS

Fifty patients were included in the study, of whom 45 were successfully discharged on the same day of the surgery. Nausea and vomiting were the most common reasons for overnight hospitalization (three patients). One patient was readmitted within the first 48 h due to a mild complication related to bleeding, resulting in a success rate of 88% for SDD without readmission within 48 h. No severe complications or mortality were reported in the cohort.

CONCLUSION

Our SDD protocol for SG has demonstrated feasibility, with a high success rate of SDD and no severe complications. Strict conditions should be met for the safe implementation of a SDD protocol, including careful patient selection and the establishment of a safety net to detect early complications.

Intra-operative Tranexamic Acid Administration Significantly Decreases Incidence of Postoperative Bleeding Without Increasing Venous Thromboembolism Risk After Laparoscopic Sleeve Gastrectomy: a Retrospective Cohort Study of Over 400 Patients

BACKGROUND

There is evidence that tranexamic acid (TXA) reduces surgical bleeding and is widely used in trauma, obstetrics and other specialties. This practice is less well-established in laparoscopic sleeve gastrectomy (LSG) due to concerns surrounding venous thromboembolism (VTE); equally postoperative bleeding is a serious complication often requiring re-operation.

METHODS

This retrospective cohort study compared 30-day outcomes following primary LSG in patients receiving intra-operative TXA (March 2020-July 2022) to those who did not (March 2011-March 2020). The primary outcome was postoperative bleeding (Hb < 9 g/dL) requiring transfusion or re-operation. Secondary outcomes were incidence of VTE, serious postoperative complications (Clavien-Dindo > grade 3) and death. Patients underwent standardised-protocol LSG without staple line re-enforcement under a single surgeon within the independent sector (private practice). TXA 1 g intravenous was administered immediately after a methylene blue leak test, prior to extubation.

RESULTS

TXA group had 226 patients and non-TXA group had 192 patients. Mean age was 40.5 ± 10.3 and 39.1 ± 9.8 years, respectively. In the TXA group, no postoperative bleeds [versus 3 (1.6%) in non-TXA group, p = 0.0279] occurred. One staple line leak (0.4%) occurred in the TXA group compared to zero in the non-TXA group (p = ns). There was no VTE or death.

CONCLUSIONS

This is the largest cohort study of intra-operative TXA in primary LSG to date, which demonstrates significant decrease in postoperative bleeding without increasing VTE risk. The authors recommend administration of TXA immediately following leak test, or removal of bougie to maximise efficacy. Data of TXA in LSG is awaited from the randomised controlled PATAS trial.

Suggested Flowchart Through Integrated C-Reactive Protein and White Blood Cell Count Analysis for Screening for Early Complications After Gastric Bypass: a Single-Center Retrospective Study

INTRODUCTION

Early leakage detection following bariatric procedures is crucial, but a standardized evaluation method is lacking. The aim was to validate the potential benefits of postoperative day 1 (POD1) C-reactive protein (CRP) levels and white blood cell (WBC) counts in distinguishing at-risk patients following Roux-en-Y gastric bypass (RYGB) while considering the impact of obesity-related chronic inflammation.

METHODS

Retrospective analysis of 261 consecutive patients aged 18-65 years with a body mass index (BMI) of 32.5-50 kg/m2 who underwent primary RYGB between 2017 and 2022. Sequential changes in CRP levels and WBC counts measured 48 h preoperatively and on POD1 morning were collected and compared between patients with/without complications and in patients without complications stratified by preoperative CRP levels.

RESULTS

Female patients and those with a higher BMI tended to have higher baseline CRP levels, which were positively related to postoperative CRP. Patients experiencing complications had higher WBC counts and a higher prevalence of WBC counts >14,000/μl (77.8% vs. 25.4%; p<0.001) than those without complications. Baseline CRP ≥ 0.3 mg/dl, a longer operative time, and blood loss >10 ml were significantly more common with WBC counts above 14,000/μl; a reasonable range of change in WBC count (∆WBC) derived from its positive correlation to postoperative WBC count (r=0.6695) may serve as a useful complementary indicator.

CONCLUSION

An individualized CRP threshold setting and integrated interpretation of the WBC count can be more appropriate than using static criteria for differentiating at-risk patients after RYGB. Further studies are needed to validate these findings and determine their generalizability.

Lessons Learned from Telemonitoring in an Outpatient Bariatric Surgery Pathway-Secondary Outcomes of a Patient Preference Clinical Trial

BACKGROUND

Remote monitoring is increasingly used to support postoperative care. This study aimed to describe the lessons learned from the use of telemonitoring in an outpatient bariatric surgery pathway.

MATERIALS AND METHODS

Patients were assigned based on their preference to an intervention cohort of same-day discharge after bariatric surgery. In total, 102 patients were monitored continuously for 7 days using a wearable monitoring device with a Continuous and Remote Early Warning Score-based notification protocol (CREWS). Outcome measures included missing data, course of postoperative heart and respiration rate, false positive notification and specificity analysis, and vital sign assessment during teleconsultation.

RESULTS

In 14.7% of the patients, data for heart rate was missing for > 8 h. A day-night-rhythm of heart rate and respiration rate reappeared on average on postoperative day 2 with heart rate amplitude increasing after day 3. CREWS notification had a specificity of 98%. Of the 17 notifications, 70% was false positive. Half of them occurred between day 4 and 7 and were accompanied with surrounding reassuring values. Comparable postoperative complaints were encountered between patients with normal and deviated data.

CONCLUSION

Telemonitoring after outpatient bariatric surgery is feasible. It supports clinical decisions, however does not replace nurse or physician care. Although infrequent, the false notification rate was high. We suggested additional contact may not be necessary when notifications occur after restoration of circadian rhythm or when surrounding reassuring vital signs are present. CREWS supports ruling out serious complications, what may reduce in-hospital re-evaluations. Following these lessons learned, increased patients' comfort and decreased clinical workload could be expected.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT04754893.

Evaluation of Postoperative Care Protocol for Roux-en-Y Gastric Bypass Patients with Same-Day Discharge

INTRODUCTION

Same-day discharge (SDD) after bariatric surgery is increasingly being performed and is safe with careful patient selection. However, detecting early complications during the first postoperative days can be challenging. We developed a postoperative care protocol for these patients and aimed to evaluate its effectiveness in detecting complications and monitoring patient recovery.

METHODS

A single-center retrospective observational study was conducted with patients with who underwent Roux-en-Y Gastric Bypass (RYGB) with successful SDD. The study evaluated the effectiveness of the safety net that included simple remote monitoring with a pulsoximeter and thermometer, a phone consultation on postoperative day (POD) 1, and a physical consultation on POD 2-4. Furthermore, an analysis was performed on various factors including pain scores, painkiller usage, and incidences of nausea and vomiting on POD 1.

RESULTS

In this study, 373 consecutive patients were included, of whom 19 (5.1%) were readmitted until POD 4. Among these, 12 patients (3.2%) reached out to the hospital themselves, while 7 (1.9%) were readmitted after phone or physical consultations. Ten of the readmitted patients had tachycardia. On POD 1, the mean numeric rating scale was 4 ± 2, and 96.6% of the patients used acetaminophen, 35.5% used naproxen, and 9.7% used oxynorm. Of the patients, 13.9% experienced nausea and 6.7% reported vomiting.

CONCLUSION

A postoperative care protocol for SDD after RYGB, comprising simple remote monitoring along with a phone consultation on POD 1 and a physical checkup on POD 2-4, was effective in monitoring patient recovery and detecting all early complications.

Feasibility of Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass in Patients with Well-Regulated Obstructive Sleep Apnea

INTRODUCTION

Same-day discharge after bariatric surgery is increasingly being performed. In current practice, patients with only minor comorbidities are considered eligible for same-day discharge after laparoscopic Roux-en-Y gastric bypass (RYGB). Obstructive sleep apnea (OSA) is a common comorbidity in patients with morbid obesity, with a prevalence of around 70-80% among patients undergoing bariatric surgery. Continuous positive airway pressure (CPAP) is the current gold standard treatment for OSA. We aimed to investigate whether same-day discharge after RYGB is feasible for patients with compliant use of CPAP.

METHODS

In this single-center prospective feasibility study, patients were selected who were scheduled for RYGB and were adequately treated for OSA. Compliance on the use of CPAP had to be proved (> 4 h per night for 14 consecutive nights). There were strict criteria on approval upon same-day discharge. The primary outcome was the rate of successful same-day discharge. Secondary outcomes included short-term complications, emergency department presentations, readmissions, and mortality.

RESULTS

Forty-nine patients underwent RYGB with intended same-day discharge, of whom 45 (92%) were successfully discharged. Three patients had an overnight stay because of divergent vital signs and one patient due to a delayed start of the surgery. Two patients (4%) were readmitted in the first 48 h postoperatively, both due to intraluminal bleeding which was managed conservatively (Clavien-Dindo 2). There were no severe complications in the first 48 h after surgery.

CONCLUSION

Same-day discharge after RYGB can be considered feasible for selected patients with well-regulated OSA.

Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass: a Cohort of 500 Consecutive Patients

INTRODUCTION

There is an increasing demand on hospital capacity worldwide due to the COVID-19 pandemic and local staff shortages. Novel care pathways have to be developed in order to keep bariatric and metabolic surgery maintainable. Same-day discharge (SDD) after laparoscopic Roux-en-Y gastric bypass (RYGB) is proved to be feasible and could potentially solve this challenge. The aim of this study was to investigate whether SDD after RYGB is safe for a selected group of patients.

METHODS

In this single-center cohort study, low-risk patients were selected for primary RYGB with intended same-day discharge with remote monitoring. All patients were operated according to ERAS protocol. There were strict criteria on approval upon same-day discharge. It was demanded that patients should contact the hospital in case of any signs of complications. Primary outcome was the rate of successful same-day discharge without readmission within 48 h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality.

RESULTS

Five hundred patients underwent RYGB with intended SDD, of whom 465 (93.0%) were successfully discharged. Twenty-one patients (4.5%) were readmitted in the first 48 h postoperatively. None of these patients had a severe bleeding. This results in a success rate of 88.8% of SDD without readmission within 48 h.

CONCLUSIONS

Same-day discharge after RYGB is safe, provided that patients are carefully selected and strict discharge criteria are used. It is an effective care pathway to reduce the burden on hospital capacity.

Telemonitoring for perioperative care of outpatient bariatric surgery: Preference-based randomized clinical trial

IMPORTANCE

Implementation of bariatric surgery on an outpatient basis is hampered by concerns about timely detection of postoperative complications. Telemonitoring could enhance detection and support transition to an outpatient recovery pathway.

OBJECTIVE

This study aimed to evaluate non-inferiority and feasibility of an outpatient recovery pathway after bariatric surgery, supported by remote monitoring compared to standard care.

DESIGN

Preference-based non-inferiority randomized trial.

SETTING

Center for obesity and metabolic surgery, Catharina hospital Eindhoven, the Netherlands.

PARTICIPANTS

Adult patients scheduled for primary gastric bypass or sleeve gastrectomy.

INTERVENTIONS

Same-day discharge with one week ongoing Remote Monitoring (RM) of vital parameters or Standard Care (SC) with discharge on postoperative day one.

MAIN OUTCOMES

Primary outcome was a thirty-day composite Textbook Outcome score encompassing mortality, mild and severe complications, readmission and prolonged length-of-stay. Non-inferiority of same-day discharge and remote monitoring was accepted below the selected margin of 7% upper limit of confidence interval. Secondary outcomes included admission duration, post-discharge opioid use and patients' satisfaction.

RESULTS

Textbook Outcome was achieved in 94% (n = 102) in RM versus 98% (n = 100) in SC (RR 2.9; 95% CI, 0.60-14.23, p = 0.22). The non-inferiority margin was exceeded which is a statistically inconclusive result. Both Textbook Outcome measures were above Dutch average (5% RM and 9% SC). Same-day discharge reduced hospitalization days by 61% (p<0.001) and by 58% with re-admission days included (p<0.001). Post-discharge opioid use and satisfaction scores were equal (p = 0.82 and p = 0.86).

CONCLUSION

In conclusion, outpatient bariatric surgery supported with telemonitoring is clinically comparable to standard overnight bariatrics in terms of textbook-outcome. Both approaches reached primary endpoint results above Dutch average. However, statistically the outpatient surgery protocol was neither inferior, nor non-inferior to the standard pathway. Additionally, offering same-day discharge reduces the total hospitalization days while maintaining patient satisfaction and safety.

The Relationship Between Tachycardia After Laparoscopic Sleeve Gastrectomy and the Development of Postoperative Complications

BACKGROUND

Bariatric surgery can be associated with severe complications. Tachycardia is an important indicator of certain complications, such as anastomotic leak and hemorrhage. Our aim was to examine the relationship between tachycardia following sleeve gastrectomy and the appearance of associated complications.

METHODS

Patients who underwent sleeve gastrectomy over a 2-year period were included in the study. Participants were divided into two groups: the first included patients who suffered from postoperative tachycardia and the second patients with normal postoperative heart rates. Complications in both groups were examined. Other parameters that predict the onset of complications were also reviewed.

RESULTS

A total of 457 patients were included. Postoperative tachycardia was measured in 181 (39.6%) patients; 17 (3.7%) suffered from bleeding and 4 (1%) from staple line leakage. Postoperative bleeding was more common among patients with tachycardia than among those without (14 (7.7%) vs. 3 (1.1%), respectively). Patients in the tachycardia group had more staple line leakages than those in the normal heart rate group (3 (2%) vs. 1 (0%), respectively); tachycardia was also attributed to postoperative pain or other minor complications in 160 (88%) patients. Age ≥ 40 years was found to be predictive factor for postoperative complications.

CONCLUSIONS

The most common causes of tachycardia postoperatively were pain and minor complications. Tachycardia is an essential indicator of postoperative minor and major complications, mainly staple line leakage and bleeding. This should prompt immediate medical intervention in order to avoid serious adverse events.

Early Postoperative Bleeding After Laparoscopic Roux-En-Y Gastric Bypass: a Single Center Analysis

PURPOSE

Early postoperative bleeding is a common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB) and is associated with significant morbidity. We aimed to identify predictors of early postoperative bleeding after LRYGB and characterize hemorrhagic events and 30-day postoperative outcomes.

MATERIAL AND METHODS

We conducted a retrospective cohort study regarding all patients submitted to LRYGB in 2019 at a high-volume obesity center. Early postoperative bleeding was defined as any clinically significant evidence of hemorrhage in the early postoperative period. Demographic, preoperative, and intraoperative factors were evaluated for associations with postoperative bleeding. Postoperative outcomes were compared between patients with and without hemorrhage.

RESULTS

Of 340 patients submitted to LRYGB, 14 (4.1%) had early postoperative bleeding. Patients with bleeding had an increased preoperative left hepatic lobe diameter (8.4 vs. 7.3 cm, p = 0.048). Prior cholecystectomy (28.6 vs. 14.5%) and previous bariatric surgery (35.7 vs. 23.9%) tended to be more prevalent among these patients. Bleeding occurred at a median time of 31.2 [IQR 19.7-38.5] h. Thirteen patients presented with intraluminal bleeding and one with extraluminal bleeding. Melena was the most common symptom. All hemorrhages were clinically diagnosed, and 92.9% were managed conservatively. Postoperative bleeding was associated with longer hospital stay (3.5 vs. 2.0 days), higher reintervention (7.1 vs. 0%), and readmission (14.3 vs. 0%), all p < 0.05.

CONCLUSIONS

Bleeding was the most frequent early complication after LRYGB. Patients with hepatomegaly and prior surgeries may have technically challenging LRYGB and should be carefully assessed. Perioperative strategies should be encouraged in high-risk patients to prevent bleeding.

Postbariatric EArly discharge Controlled by Healthdot (PEACH) trial: study protocol for a preference-based randomized trial

Introduction

Performing bariatric surgery in a daycare setting has a potential reduction in hospital costs and increase in patients’ satisfaction. Although the feasibility and safety of such care pathway has already been proven, its implementation is hampered by concerns about timely detection of short-term complications. This study is designed to evaluate a combined outcome measurement in outpatient bariatric surgery supplemented by a novel wireless remote monitoring system versus current standard of care.

Methods and analysis

A total of 200 patients with multidisciplinary team approval for primary bariatric surgery will be assigned based on their preference to one of two postoperative trajectories: (1) standard of in-hospital care with discharge on the first postoperative day or (2) same day discharge with ongoing telemonitoring up to 7 days after surgery. The device (Healthdot R Philips) transfers heart rate, respiration rate, activity, and body posture of the patient continuously by LoRaWan network to our hospital’s dashboard (Philips Guardian). The primary outcome is a composite outcome measure within 30 days postoperative based on mortality, mild and severe complications, readmission, and prolonged length-of-stay. Secondary outcomes include patients’ satisfaction and data handling dimensions.

Trial registration

ClinicalTrials.govNCT04754893, Registered on 12 February 2021.

Clinical Indicators of Postoperative Bleeding in Bariatric Surgery

The purpose of this study was to evaluate the relationship between patient, clinical and laboratory characteristics, and bleeding after bariatric surgery. A retrospective chart review was performed for all patients, who underwent a laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy at our institution between March 2012 and May 2014. In total, 788 patients were included in this study. Seventeen patients had postoperative bleeding. The demographics, comorbidities, and preoperative medications were similar between the groups. Mean postoperative hemoglobin in the bleeding group was significantly lower (94 vs. 126; P<0.001) with a larger decrease from the baseline value (-43 vs. -12; P<0.001). The mean heart rate (91 vs. 81; P<0.001) and its increase from baseline (12 vs. -0.01; P<0.001) were significantly different in the bleeding patients. Postoperative hemoglobin and heart rate were associated with bleeding but not systolic blood pressure or patient characteristics. Further research is needed to develop a robust predictive model.

Management of acute intra-abdominal sepsis caused by leakage after one anastomosis gastric bypass

BACKGROUND

Leakage after one-anastomosis gastric bypass (OAGB) is fortunately rare (<1%), but it remains the most severe complication. Few published data exist on this specific issue.

OBJECTIVES

To analyze the results from patients who presented with acute intra-abdominal sepsis (AIAS) caused by leakage after OAGB.

SETTING

A university public hospital in France.

METHODS

Between October 2006 and February 2016, 17 consecutive patients with a diagnosis of AIAS caused by leakage after OAGB were included. Preoperative characteristics, clinical symptoms, radiologic findings, management, morbidity, and mortality were assessed.

RESULTS

All 17 patients were included in the study. There were 4 men (23.5%), the median age was 48 years, and median preoperative body mass index (BMI) was 51 kg/m². The most frequent clinical sign was tachycardia (65%). An oral contrast computed tomography scan was performed in 15 patients (88%) and showed a diagnosis of AIAS in 93% of cases. The median time between OAGB and leak diagnosis was 4 days. A gastrojejunal anastomosis (GJA) leak was the most frequent origin (41%). Sixteen patients (94%) were managed surgically (laparotomy n = 11, laparoscopy n = 5) and one medically. There were no deaths. The overall morbidity rate was 47% (major = 41%). Six patients underwent an emergency conversion into Roux-en-Y gastric bypass (RYGB) (in cases of GJA, gastric-tube, and biliary-limb leakages) and were compared to 6 patients who did not undergo conversion but who could have benefited. We observed a tendency toward a reduced overall morbidity rate (16.7% versus 83.3%, P = .08) and shorter lengths of stay in the "conversion to RYGB" group.

CONCLUSION

The management of AIAS caused by leakage after OAGB was safe, effective, and mostly surgical. Emergency conversion to RYGB in cases of GJA, gastric-tube, or biliary-limb perforation was feasible and safe.

Postpercutaneous Nephrolithotomy Systemic Inflammatory Response Syndrome Is Not Associated With Unplanned Readmission

OBJECTIVE

To investigate the incidence of systemic inflammatory response syndrome (SIRS) following percutaneous nephrolithotomy (PCNL) and evaluate any association with unplanned 90-day readmission.

METHODS

We retrospectively reviewed consecutive patients undergoing PCNL in 2 dedicated endourologic practices between 2009 and 2013. We collected patient demographics, perioperative culture data, and operative characteristics. SIRS was defined as having 2 or more of the following: maximum white blood cell count >12,000 or <4000, temperature >38 or <34°C, heart rate >90, and respiratory rate >20 within the first 24 hours following PCNL. Proportions between groups were compared to identify significant associations.

RESULTS

We identified 389 patients undergoing PCNL and 43% (167 of 389) met SIRS criteria, more commonly in patients with multiple PCNL accesses (OR 2.3; CI: 1.1-4.8, P = .025). Readmission was required in 8% (31 of 389), most commonly for infection (n = 21). Although possession of a struvite stone was associated with unplanned readmission (16% vs 4%, P < .01), SIRS in the absence of fever within 48 hours postoperative was not associated with readmission (29.4% vs 25.8%, P = .837).

CONCLUSION

Nearly half of the patients undergoing PCNL met the criteria for SIRS within the first postoperative day. There was no association between SIRS and unplanned readmission in the postoperative PCNL patient. Despite discharge during the first postoperative day, patients with SIRS (without fever or struvite stones) had no increased risk for unplanned return. Our findings suggest that the development of SIRS immediately following PCNL does not preclude safe discharge on the first postoperative day.

The clinical significance of postoperative tachycardia following ventral hernia repair

BACKGROUND

Early identification of serious adverse events following ventral hernia repair (VHR) could result in improved patient outcomes. Establishment of clinical markers that correlate with serious adverse events following VHR would help facilitate a more timely diagnosis of such events. We investigated the clinical utility of postoperative tachycardia to predict serious adverse events in patients undergoing VHR.

METHODS

Consecutive patients undergoing VHR at the Cleveland Clinic Comprehensive Hernia Center from September 2013 through June 2015 were identified within the Americas Hernia Society Quality Collaborative database. Tachycardia was classified according to frequency and duration. Sustained tachycardia was defined as >8 consecutive hours of tachycardia on any postoperative day. Serious adverse events were defined as cardiac events, venous thromboembolism, infection, bleeding, and anastomotic leak or missed enterotomy. Association between tachycardia class and serious adverse events was investigated using the Pearson χ(2) test.

RESULTS

A total of 377 patients underwent VHR during the study period. A total of 119 (31.6%) patients experienced at least 1 episode of tachycardia. There were 26 (6.9%) patients with a serious adverse event. Tachycardia was present in 21 (80.7%) of these patients. Sustained tachycardia had a significant association with serious adverse events (P = .007). The presence of postoperative tachycardia was associated with the occurrence of a serious adverse event, having a positive likelihood ratio of 2.9 (95% confidence interval 2.2-3.7).

CONCLUSION

Postoperative tachycardia is common following VHR. Nevertheless, sustained tachycardia is associated with a significant risk for serious postoperative adverse events and mandates further investigation.

Laparoscopic, hybrid, and totally robotic Roux-en-Y gastric bypass

The laparoscopic approach to Roux-en-Y gastric bypass (RYGB) is a highly regarded and frequently used bariatric procedure. We review our experience with robotic approaches to RYGB. We hypothesized that the robotic approach is safe and may produce similar outcomes to previously reported laparoscopic surgery. We conducted our study at the University Hospital, USA. Data regarding RYGB procedures performed in 2006-2013 were retrospectively reviewed from a prospectively maintained, dedicated database. Procedures were categorized into three groups: laparoscopic, hybrid robotic (HR), and total robotic (TR). Patient characteristics, operative variables, and postoperative short- and long-term outcomes were compared between groups and to recently published larger laparoscopic series. Our study included 192 RYGB consecutive patients who underwent laparoscopic, HR, or TR surgery. Mean patient age, preoperative body mass index, and preoperative weight were 40.4 ± 9.3 years (range 22-64), 46. 2 ± 5.9 kg/m(2) (range 35-64), and 130. 3 ± 22.1 kg (range 76.7-193.4) respectively. Ninety-two patients (47.9 %) had undergone previous abdominal surgery. Mean operative time, estimated blood loss, and length of stay were 223.4 ± 39.2 min (range 130-338), 21.9 ± 18.8 mL (range 5-10), and 2.6 ± 1.1 days (range 2-15), respectively. There were 248 concomitant procedures such as upper endoscopy, cholecystectomy, etc., 7 revisional surgeries, and 2 conversions to open surgery. Intraoperative complications included one liver laceration and one bowel injury. There were two cases each of bowel obstruction, transfusions, and deep vein thrombosis/pulmonary embolus, but no deaths or anastomotic leaks. Early experience with TR approach for RYGB is safe, with similar outcomes to the laparoscopic approach.

Endoscopic management of bariatric surgery complications: what the gastroenterologist should know

Obesity is a serious disorder in almost the entire world. It is an important risk factor for a series of conditions that affect and threaten health. Currently, bariatric surgery is the most effective treatment for morbid obesity, and in addition to the resulting weight loss, it reduces morbidity in this population. There has been a significant increase in the number of obese patients operated on. Despite the success of bariatric surgery, an important group of patients still present with major postoperative complications. In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. The present article is a review of the resulting anatomic aspects of the main surgical techniques employed, the most common postoperative symptoms, the potential complications, and the possibilities that endoscopic diagnosis and treatment offer. Endoscopy is a growing and continuously evolving method in the treatment of bariatric surgery complications. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population.

Early post-operative complications: incidence, management, and impact on length of hospital stay. A retrospective comparison between laparoscopic gastric bypass and sleeve gastrectomy

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common obesity surgeries. Their early complications may prolong hospital stay (HS).

METHODS

Data for patients who underwent LRYGB and LSG in our clinic from 2009 through August 2012 were collected. Early post-operative complications prolonging HS (>5 days) were retrospectively analyzed, highlighting their relative incidence, management, and impact on length of HS.

RESULTS

Sixty-six patients (4.9 %) after 1,345 LRYGB operations vs. 49 patients (7.14 %) after 686 LSG operations developed early complications. This difference is statistically significant (p = 0.039). Male gender percentage was significantly higher in complicated LSG group vs. complicated LRYGB group [23 patients (46.9 %) vs. 16 patients (24.2 %)] (p = 0.042). Mean BMI was significantly higher in the complicated LSG group (54.2 ± 8.3) vs. complicated LRYGB group (46.8 ± 5.7; p = 0.004). Median length of HS was not longer after complicated LSG compared with complicated LRYGB (11 vs. 10 days; p = 0.287). Leakage and bleeding were the most common complications after either procedure. Leakage rate was not higher after LSG (12 patients, 1.7 %) compared with LRYGB (22 patients, 1.6 %; p = 0.304). Bleeding rate was significantly higher after LSG (19 patients, 2.7 %) than after LRYGB (10 patients, 0.7 %; p = 0.004). Prolonged elevation of inflammatory markers was the most common presentation for complications after LSG (18 patients, 36.7 %) and LRYGB (31 patients, 46.9 %).

CONCLUSIONS

LSG was associated with more early complications. This may be attributed to higher BMI and predominance of males in LSG group.

Factors predicting the occurrence of a gastrojejunal anastomosis leak following gastric bypass

Introduction

Occurrence of anastomotic leaks following Roux-en-Y gastric bypass (RYGB), arising principally from the gastro-jejunal anastomosis, is associated with significant morbidity and mortality. Their early detection and treatment is essential. However, a significant number of postoperative oral contrast studies fail to identify leaks, and a negative study providing false reassurance can lead to a delay in diagnosis and treatment. Physiological features including tachycardia, increased respiratory rate and pyrexia or elevations in C-reactive protein and white cell count are seen in patients with leaks. In this study we examine physiological and laboratory parameters in patients with and without anastomotic leaks following RYGB to try and improve the detection of leaks.

Aim

To evaluate clinical signs and laboratory tests in determination of the development of gastrojejunal leaks after gastric bypass surgery.

Material and methods

The study examined 116 consecutive patients undergoing laparoscopic RYGB. Clinical signs and laboratory results were reviewed retrospectively.

Results

Four gastrojejunostomy leaks in our series were identified after RYGB surgery. All these patients were treated successfully. Leak patients’ in-hospital stay was longer. Tachycardia among leak patients occurs from day 1 with 100% sensitivity and 87% specificity at a cut-off point of 90 bpm. A temperature difference appears on day 2 in leak patients. The CRP was higher on day 2 and 3 in leak patients. Higher intravenous fluid requirements were observed in patients with leaks.

Conclusions

Gastrojejunal anastomosis leak is associated with longer in-hospital treatment. The earliest significant indicators of a leak are tachycardia and positive fluid balance. A temperature spike and CRP rise occur on day 2. Leak patients matched SIRS WBC count criteria on day 3.

[Redo intervention and complication management in bariatric surgery]

Morbid obesity and the associated comorbidities are rapidly increasing worldwide. Bariatric surgery has proven to be an effective treatment option. In 2011 more then 340,000 bariatric procedures were performed worldwide which is accompanied by a growing demand for revision bariatric procedures due to complications or failure, such as insufficient weight loss or weight regain.Redo operation procedures as well as the management of complications require a profound preoperative medical history and diagnostic investigation in combination with an exact knowledge of the anatomical changes made in the primary procedure.

Diagnostic markers of postoperative morbidity after laparoscopic Roux-en-Y gastric bypass for obesity

PURPOSE

The main objective of this study was to detect subacute complications that can arise from laparoscopic Roux-en-Y gastric bypass and take a rational approach to manage these complications.

METHODS

A prospective observational study was performed from November 2010 to December 2012. All patients undergoing gastric bypass surgery for morbid obesity were included in this study. Patients with complications before day 5 were excluded from the study. Clinical and laboratory data (C-reactive protein, leukocyte count) at postoperative day 5, 30-day morbidity, were recorded. The diagnostic value of C-reactive protein (CRP) and leukocytes were determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

One hundred and twenty-six patients were included. The overall incidence of 30-day morbidity was 8.7 %, and anastomotic leakage rate was 3.2 %. C-reactive protein at postoperative day 5 was a good predictor of complications (AUC was 0.862 (95 % CI [0.76; 0.96]; p < 0.001) and anastomotic leakage (AUC was 0.863 (95 % CI [0.66; 1]; p = 0.014). A CRP cutoff level of 136 mg/l at postoperative day 5 yielded a specificity of 95.5 % and a sensitivity of 57.1 % for the detection of postoperative complications. The negative predictive value was 94.6 %. A CRP level of 136 mg/l at day 5 was significantly associated with postoperative morbidity.

CONCLUSIONS

C-reactive protein dosage at postoperative day 5 is a relevant predictor of postoperative complications permitting to select patients at risk. Radiological examination and close monitoring could be restricted to patients with CRP level exceeding 136 mg/l.

Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force

BACKGROUND

Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures.

METHODS

Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies.

RESULTS

A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery.

CONCLUSION

The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.

Robot-assisted versus laparoscopic gastric bypass: comparison of short-term outcomes

BACKGROUND

Roux-en-Y gastric bypass is an effective treatment for severe obesity and obesity-related comorbidities. Presently, gastric bypass is performed most often laparoscopically, although a robotic-assisted procedure is the preferred approach for an increasing number of bariatric surgeons.

METHODS

This retrospective study compared the results of 100 Roux-en-Y gastric bypass operations using the da Vinci robot and 100 laparoscopic Roux-en-Y gastric bypasses performed laparoscopically. Short-term outcomes were determined by evaluating mortality, length of stay, length of operation, return to the operating room within 90 days of operation, conversions to open procedure, leaks, strictures, transfusions, and hospital readmissions.

RESULTS

There was no mortality, pulmonary embolus, or conversion to open procedure in either group. Both the laparoscopic and robotic operative times decreased progressively, although the robotic operation time was longer (mean, 144 versus 87 min, P < 0.001). The length of stay was shorter for the robotic-assisted group (37 versus 52 h, P < 0.001), and 60% of these patients were discharged after one night's stay (P < 0.001). There were fewer transfusions (P = 0.005) and readmissions (P = .560) in the robotic group. The stricture rate was higher in the first 50 robotic procedures (17 mm gastrotomy) but resolved in the second 50 procedures (21 mm gastrotomy). There was no difference in the rate of leak and return to the operating room between groups (both P > 0.05).

CONCLUSIONS

These results indicate that Roux-en-Y gastric bypass can be performed safely with robotic assistance, even during the first 100 cases.

The role of drainage after Roux-en-Y gastric bypass for morbid obesity: a systematic review

BACKGROUND

Intraperitoneal drainage after gastrointestinal surgery is still routinely used in many hospitals. The objective of this study was to determine the evidence-based value of routine drainage after Roux-en-Y gastric bypass (RYGB).

METHODS

An electronic search of the MEDLINE, Cochrane, and Embase databases from 2002 to 2012 was performed to identify articles analyzing the use of drainage after RYGB, its efficacy in determining the presence of an anastomotic leak, and its role in nonoperative treatment of the leakage.

RESULTS

Eighteen articles were identified: 6 nonrandomized prospective cohort studies, 1 cohort retrospective study that compared routine drainage versus no drainage, 11 retrospective cohort studies, and no randomized controlled trials (RCTs). The sensitivity of drainage in detecting postoperative leakage varied between 0% and 94.1% in 10 articles (3 prospective and 6 retrospective) reporting data about this matter. The efficacy of drainage for the nonoperative treatment of postoperative leakage could be estimated in 11 articles (5 prospective and 6 retrospective) and varied between 12.5% and 100%. Only 2 studies reported data about nonoperative treatment of leakage without drainage, which was pursued in 0% and 33% of patients, respectively.

CONCLUSION

Evidence-based recommendations on the use of drainage after RYGB cannot be given. Without RCTs, the value of routine drainage cannot be ascertained.

Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity

Obesity has become a major health concern in Canada. This has resulted in a steady rise in the number of bariatric surgical procedures being performed nationwide. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is not only the most common bariatric procedure, but also the gold standard to which all others are compared. With this in mind, it is imperative that all gastrointestinal surgeons understand the LRYGB and have a working knowledge of the common postoperative complications and their management. Early postoperative complications following LRYGB that demand immediate recognition include anastomotic or staple line leak, postoperative hemorrhage, bowel obstruction and incorrect Roux limb reconstructions. Later complications may be challenging to differentiate from other gastrointestinal disorders and include anastomotic stricture, marginal ulceration, fistula formation, weight gain and nutritional deficiencies. We discuss the principles involved in the management of each complication and the timing of referral to specialist bariatric centres.

Complications of Roux-en-Y gastric bypass and sleeve gastrectomy

Roux-en-Y gastric bypass and sleeve gastrectomy are two of the most common bariatric procedures performed in 2011. Although the complication rates associated with these procedures are low, the consequences of these complications are significant and can be associated with high morbidity and mortality. Timely diagnosis and proper management of these complications are extremely important. The most commonly used radiologic studies in bariatric surgery are the upper GI contrast study and the CT scan, which are used to rule out leak, obstruction, perforation, anastomotic stricture, or pouch dilatation. As with all imaging studies, a negative result should not override strong clinical suspicion of a complication.

The role of upper gastrointestinal endoscopy in treating postoperative complications in bariatric surgery

There are an estimated 500 million obese individuals worldwide. Currently, bariatric surgery has been shown to result in clinically significant weight loss. With increasing demand for bariatric surgery, endoscopic techniques used intra and postoperatively continue to evolve. Endoscopic evaluation of anastomotic integrity following RYGB allows for early detection of anastomotic leaks. Furthermore, endoscopy is a valuable tool to diagnose and treat RYGB postoperative surgical complications such as anastomotic leakage, hemorrhage and stricture formation. Early evidence suggests that endoscopic management of upper gastrointestinal hemorrhage following RYGB is effective. In addition, endoscopic balloon dilatation is able to effectively treat obstruction in the setting of gastrojejunal anastomotic strictures. With successful endoscopic management of these complications, bariatric patients may avoid more invasive surgical procedures.

Early and late abdominal bleeding after Roux-en-Y gastric bypass: sources and tailored therapeutic strategies

Bleeding is a potentially serious complication after Roux-en-Y gastric bypass (RYGB). Preventive measures and therapeutic strategies have not been adequately defined. We reviewed data on 742 consecutive patients treated at the University of California San Francisco to identify cases of early and late bleeding (less or greater than 30 days after surgery) after RYGB. Bleeding was defined as symptoms or signs of bleeding, associated with blood transfusion. We recorded patient characteristics, details of the operative technique, diagnostic approach, therapeutic strategies, and outcomes. Twenty-six patients (3.5%) had postoperative bleeding, which mostly occurred in the first 30 days postoperatively (N=19). Hematocrit decreased significantly from preoperative values (-5.2 ± 3.1 without bleeding vs. -14.8 ± 4.7 with, p<0.01). Type 2 diabetes was more prevalent in patients who had bleeding (58% vs. 32%, p=0.03). No other patient characteristics or details of the operative technique were associated with different rates of bleeding. Therapeutic intervention other than transfusion was needed for seven patients with early bleeding (36.8%) and for all patients with late bleeding. Four patients with early bleeding required reoperation. Early bleeding source was intraluminal in four patients, intraperitoneal in five, and self-limited and of unknown location in ten. Late bleeding occurred on average at 62.6 months (range, 5 to 300 months) after index surgery, five patients required reoperation, and the source was always intraluminal. Bleeding after RYGB may be from various anatomic sites; details of the operative technique were not associated with different rates of bleeding, and therapy should be tailored to suspected location of bleeding.