Rationale for laparoscopic gastric bypass

Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items

BACKGROUND

An estimated 1,500 operations result in retained surgical items (RSIs) each year in the United States, resulting in substantial morbidity. The rarity of these events makes studying them difficult, but miscount incidents may provide a window into understanding risk factors for RSIs.

METHODS

A cohort study of all consecutive operative cases during a 12-month period was conducted at a large academic medical center to identify risk factors for surgical miscounts. A multidisciplinary electronic miscount reconciliation checklist (necessitating both surgeon and nurse input) was introduced into the internally developed electronic Perioperative Information Management System to build a predictive model for RSI cases.

RESULTS

Among 23,955 operations, 84 resulted in miscount incidents (0.35% [95% confidence interval: 0.28% to 0.43%]). Increased case duration was strongly associated with increased risk of a miscount in unadjusted analyses (p < .0001). In the nested case-control analysis, both the case duration and the number of providers present were independently associated with a more than doubling of the odds of a miscount, even after adjustment for one another, the elective/urgent/emergent status of a case, and personnel changes occurring during the case.

CONCLUSIONS

The finding that both the length of the case and the number of providers involved in the case were independent risk factors for miscount incidents may offer insight into risk-targeted strategies to prevent RSIs, such as postoperative imaging, bar-coded surgical items, and radiofrequency technology. Miscounts trigger use of the Incorrect Count Safety Checklist, which can be used to determine whether a count completed at the procedure's conclusion is consistent across disciplines (circulating nurses, scrub persons, surgeons).

Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB)

INTRODUCTION

Internal hernias continue to be a significant source of morbidity after LRYGB. Literature addressing the technique of Roux limb construction as a predisposing factor is sparse. The objective of this study is to evaluate the impact of Roux limb construction technique on the development of internal hernias.

METHODS

In this study, we included 444 (367 (82.7%) were females and 77 (17.3%) were males, two deaths excluded from the analysis) consecutive patients from our institutional bariatric database who underwent LRYGB. Variables collected include demographics, body mass index (BMI) before and after the procedure, and postoperative small bowel obstruction secondary to internal herniation. Technical details collected include: type of Roux-en-Y limb construction, Peterson's defect closure at initial operation, and reoperative findings. Roux limbs were constructed in 291 patients by a clockwise rotation of the bowel and jejunojejunostomy performed on the right side of the axis of the mesentery (group 1). In 151 patients, the Roux limb was constructed by a counterclockwise rotation of the Roux limb resulting in the jejunojejunostomy on the left side of the axis of the mesentery (group 2). We also analyzed the impact of Peterson's space closure on internal hernias. Fisher's exact test and Chi-square test were used for the analysis.

RESULTS

Of a total 442 (mean age, 43.7 ± 10.3 years; mean BMI pre-op was 46.4 ± 5.1; and BMI after median follow-up of 12 months was 34.5 ± 6.98) patients included in the study, 21 (4.7%) internal hernias were identified. Of 21 internal hernias, 17 (81%) were through Peterson's space and four (19%) were through the mesenteric defect. Group 1 patients had significantly higher overall internal hernias (20/291, 6.9% vs. 1/151, 0.7%; P = 0.0018) and Peterson's hernias (16/291, 5.5% vs. 1/151, 0.7%; P = 0.0089) compared with group 2. In addition, no significant difference was noted in the incidence of Peterson's hernia whether the defect was closed or not closed (closed group, 4/117 and 3.4% vs. not closed, 13/325, 4%; P = 1.00). Within the group where Peterson's defect was closed, clockwise rotation and anastomosis on the right side of the axis of the mesentery was associated with significantly higher incidence of Peterson's hernias compared with counterclockwise rotation (4/54 vs. 0/63; P = 0.043). In the group where Peterson's defect was not closed, clockwise rotation was associated with higher incidence of internal hernias that did not reach statistical significance (12/237, 5.1% vs. 1/88, 1.1%; P = 0.12). This study demonstrates that the technique for construction of the Roux limb is a major factor in the development of internal hernias. Construction of the Roux limb with a counterclockwise rotation of the bowel, such that both jejunojejunostomy anastomosis and ligament of Treitz are to the left of the axis of the mesentery significantly reduces the incidence of internal hernias.

Efeitos da cirurgia bariátrica sobre a síndrome metabólica

RACIONAL: A obesidade mórbida é um estado de resistência à insulina associado ao excesso de gordura visceral, condições que contribuem para o desenvolvimento da síndrome metabólica. Na obesidade, os tratamentos conservadores promovem melhora da síndrome metabólica, mas a recuperação de peso é frequente. A derivação gástrica em Y-de-Roux resulta em perda de peso, mais significativa e sustentada, além de promover melhora da síndrome metabólica, que é condição de risco para o desenvolvimento de doença aterosclerótica sistêmica. OBJETIVO: Demonstrar que a cirurgia bariátrica promove a reversão da síndrome metabólica. MÉTODOS: O estudo foi realizado com 74 pacientes obesos, submetidos a derivação gástrica em Y-de-Roux por videolaparoscopia. Foram avaliados por meio de dados antropométricos e laboratoriais, com a aferição do peso, circunferência abdominal, índice de massa corporal, pressão arterial sistêmica e a dosagem de glicemia, triglicérides, colesterol total e sua fração HDL, no pré-operatório e ao longo de seis meses após a operação. Para comparação de médias foi utilizado o teste não paramétrico de Friedman e, quando necessário, o teste de Wilcoxon, considerando nível de significância valor de p<0,05. RESULTADO: Houve 52 mulheres e 22 homens, com a média de idade de 34,6 anos. O intervalo de seguimento foi de seis meses. A média do índice de massa corporal no pré-operatório era de 42 e após seis meses foi de 29,6. Demonstrou-se diferença estatisticamente significativa entre os momentos, quanto a todas as variáveis quantitativas analisadas. CONCLUSÃO: Pôde-se inferir que a cirurgia bariátrica é meio eficaz de perda de peso e normalização precoce das alterações antropométricas e laboratoriais utilizadas no diagnóstico da síndrome metabólica.

Intraoperative endoscopy for laparoscopic Roux-en-Y gastric bypass: leak test and beyond

INTRODUCTION

The aim of this study is to determine the role of intraoperative endoscopy in identifying gastrojejunostomy leak in laparoscopic Roux-en-Y gastric bypass (LRNYGB) and to define other roles that can be achieved by this diagnostic maneuver.

METHODS

A retrospective chart review of all patients who underwent LRNYGB at both Cleveland Clinic (USA) and Adan Hospital (Kuwait) was undertaken. All operations were performed by 2 surgeons (B.C. and F.A.).We analyzed the following parameters in the patients: mean age, estimated blood loss, average hospital stay, the number of patients who had intraoperative leaks, and those who developed intraoperative pouch bleeding.

RESULTS

Between July 2004 and January 2009, 290 patients (244 women-85% and 46 men-15%) were operated upon with a mean age of 42 years (range: 19 to 61 y). The average body mass index was 48 kg/m2 (range: 35 to 65 kg/m2), and the average American Society of Anesthesiology classification of 3 (range: 2 to 4). Mean estimated blood loss of 95 mL (range: 27 to 310 mL) and the mean operative time was 165 minutes (range: 102 to 348 min). The average hospital stay was 3 days (range: 2 to 13 d). Eleven patients (3.7%) developed intraoperative leaks that were controlled intraoperatively. Ten patients (3.4%) developed intraoperative pouch bleeding, in 6 of them the bleeding vessel was controlled laparascopically. No documented postoperative leak in this series of patients. One patient (0.34%) underwent diagnostic laparoscopy for clinical suspicion of a leak which could not be identified.

CONCLUSIONS

Intraoperative endoscopy for LRNYGBP may reduce the leak rate postoperatively and also, may minimize postoperative endoscopy and surgical intervention for gastrointestinal bleeding.

Laparoscopic Roux-en-Y gastric bypass in patients with body mass index >70 kg/m2

BACKGROUND

Sparse published data support the optimal surgical management of megaobesity (body mass index >70 kg/m(2)). The purpose of the present study was to compare laparoscopic Roux-en-Y gastric bypass (LRYGB) and open Roux-en-Y gastric bypass (ORYGB) in megaobese patients.

METHODS

We conducted a retrospective review of 89 consecutive patients with a body mass index >70 kg/m(2) who underwent LRYGB or ORYGB from January 2003 to May 2007 at the Ohio State University Medical Center.

RESULTS

LRYGB was performed in 37 patients, with 3 conversions to open surgery, and 52 underwent ORYGB. No statistically significant demographic or preoperative co-morbidity differences were discerned. The mean intraoperative blood loss was lower in the LRYGB group (54 mL versus 211 mL; P < .0001). The median length of stay for both LRYGB and ORYGB groups was 4 days. One patient in the open group died. The postoperative complications were statistically equivalent between the 2 groups. The hernia rate for the LRYGB group was 3% and was 19% in the ORYGB group (P = .02). The patients who underwent LRYGB had greater excess body weight loss at 3 (22.7% versus 17.5%, P = .02) and 6 (37.5% versus 30.5%, P = .03) months. However, the average excess body weight loss at 12 and 24 months was similar (48% and 60%, respectively).

CONCLUSION

LRYGB is a technically feasible and safe surgical approach in the megaobese. The intraoperative blood loss was less with LRYGB than with ORYGB. The overall mortality and complications were not different, with the exception of hernia frequency, which was significantly greater after ORYGB. The percentage of excess body weight loss at 3 and 6 months was better for the LRYGB group. In both groups of patients, the 12- and 24-month excess body weight loss were similar.

Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness

BACKGROUND

New technologies are available to reduce or prevent retained surgical sponges (RSS), but their relative cost effectiveness are unknown. We developed an empirically calibrated decision-analytic model comparing standard counting against alternative strategies: universal or selective x-ray, bar-coded sponges (BCS), and radiofrequency-tagged (RF) sponges.

METHODS

Key model parameters were obtained from field observations during a randomized-controlled BCS trial (n = 298), an observational study of RSS (n = 191,168), and clinical experience with BCS (n approximately 60,000). Because no comparable data exist for RF, we modeled its performance under 2 alternative assumptions. Only incremental sponge-tracking costs, excluding those common to all strategies, were considered. Main outcomes were RSS incidence and cost-effectiveness ratios for each strategy, from the institutional decision maker's perspective.

RESULTS

Standard counting detects 82% of RSS. Bar coding prevents > or =97.5% for an additional $95,000 per RSS averted. If RF were as effective as bar coding, it would cost $720,000 per additional RSS averted (versus standard counting). Universal and selective x-rays for high-risk operations are more costly, but less effective than BCS-$1.1 to 1.4 million per RSS event prevented. In sensitivity analyses, results were robust over the plausible range of effectiveness assumptions, but sensitive to cost.

CONCLUSION

Using currently available data, this analysis provides a useful model for comparing the relative cost effectiveness of existing sponge-tracking strategies. Selecting the best method for an institution depends on its priorities: ease of use, cost reduction, or ensuring RSS are truly "never events." Given medical and liability costs of >$200,000 per incident, novel technologies can substantially reduce the incidence of RSS at an acceptable cost.

Article Commentary: Retained Intra-abdominal Surgical Instruments: Time to Use Nascent Technology?

Retention of surgical instruments is a possible complication of surgery; moreover, its occurrence has typically been used to denote poor surgical care on the part of the individual surgeon and the healthcare system. In the literature, it is not surprising that instances of retained foreign bodies are underreported to minimize exposure to possible litigation.

Laparoscopic Roux-en-Y gastric bypass for BMI <35 kg/m2: a tailored approach

BACKGROUND

Patients with a body mass index (BMI) < 35 kg/m(2) who are obese, have uncontrolled co-morbidities, and have tried to lose weight with no success do not meet the "traditional" criteria for obesity surgery, and no other treatment is being offered to them.

METHODS

A total of 37 obese patients (30 women and 7 men) had been undergoing clinical treatment with no resolution or improvement of their life-threatening co-morbidities. The mean BMI was 32.5 kg/m(2). Their age ranged from 28 to 45 years. All patients had type 2 diabetes mellitus, hypertension, and lipid disorder. Gastroesophageal reflux disease was present in 7 patients and sleep apnea in 3. These patients underwent the same preoperative evaluation as other patients for gastric bypass. The patients were required to have approval from their primary care physician. All patients provided written informed consent. Laparoscopic Roux-en-Y gastric bypass was performed. After extensive explanation and documentation, the Brazilian insurance companies approved the procedure in 3 cases, and international (non-American) insurance companies approved the procedure in 4 cases.

RESULTS

The follow-up range was 6-48 months. The mean excess weight loss was 81%. Thirty-six patients had total remission of their co-morbidities. One patient still had mild hypertension, but with a reduction in the number of antihypertensive drugs used. No surgery-related complications occurred.

CONCLUSION

Obese patients with a BMI of <35 kg/m(2) and severe co-morbidities can benefit from laparoscopic Roux-en-Y gastric bypass. This treatment option should be offered to this group of patients.

Laparoscopic skills laboratories: current assessment and a call for resident training standards

BACKGROUND

Numerous protocols for laparoscopic skills training using simulator-based laboratories have proven effective. However, little is known about the availability and uniformity of such facilities. The purpose of this study was to evaluate the prevalence, utilization, and costs of skills laboratories currently in use.

METHODS

A survey was mailed to 253 general surgery program directors to determine the perceived value, prevalence, equipment, types of training, supervision, and costs of the labs.

RESULTS

One hundred sixty-two (64%) programs completed the survey. Eighty-eight percent of responders consider skills labs effective in improving operating room performance; however, only 55% have skills labs. Of 89 programs with skills labs, 99% have videotrainer equipment (mean 3.8 trainers per lab, range 1 to 15); 46% have virtual reality trainer equipment (mean 1.7 trainers per lab, range 1 to 7). Eighty-two percent of programs teach basic skills using a variety of tasks (Rosser/Southwestern stations, MIST-VR, MISTELS, department-created); 96% teach suturing (intracorporeal, extracorporeal, suture devices). On average, residents train 0.8 hours per week (range 0 to 6). Training is mandatory in 55% and supervised in 73% of the programs. The mean development cost was 133,000 dollars (range 300 dollars to 1,000,000 dollars).

CONCLUSIONS

While a large majority of program directors consider skills labs important, 45% of programs have no such facilities. Moreover, significant variability of equipment and training practices exist in currently available labs. Strategies are needed for more widespread implementation of skills labs, and standards should be developed to facilitate uniform adoption of validated curricula that reliably maximize training efficiency and educational benefit.

Endoscopic issues in the post-gastric bypass patient

Obesity in the United States poses a tremendous health risk to approximately one third of the population. As this epidemic grows, the number of bariatric surgeries performed will also increase. Although obesity itself is not gender specific, 85% of bariatric surgeries are performed in women. This article reviews some of the commonly performed weight-reduction surgeries and their associated complications. Particular emphasis is placed on the diagnostic and therapeutic implications of endoscopy in this population.