Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs

Incisional hernia incidence following laparoscopic versus open abdominal surgery: an updated systematic review and meta-analysis of randomized controlled trials

PURPOSE

Incisional hernias (IH) are a frequent complication following open surgery (OP). While laparoscopic (LAP) surgery is designed to enhance patient recovery through smaller incisions, contemporary quantitative evidence supporting its efficacy in reducing IH rates (IHR) is sparse. This study aims to provide an overview of IHR following OP and LAP abdominal operations.

METHODS

We searched for randomized controlled trials (RCTs) studies in PubMed, Cochrane, and Embase from inception until May 2024 comparing OP approach to LAP and reported IH incidence as a postoperative complication. Exclusion criteria included studies involving patients aged ≤ 18 years, those lacking a control group, or those with a follow-up period of less than 12 months. Studies were stratified by procedure type and by fully laparoscopic (T-LAP) versus laparoscopic-assisted (LAP-A) approaches. Statistical analyses were performed using RStudio software. To address potential clinical and methodological heterogeneity across studies, we applied the restricted maximum-likelihood estimator and random-effects models for outcome analysis.

RESULTS

8.754 studies were screened, and 72 studies were reviewed. From the initial screening, 28 studies involving 6,113 patients were included, of which 3,337 (54.6%) underwent LAP. Analysis revealed a significantly lower incidence of IH among patients who received LAP (RR 0.51; 95% CI 0.33-0.79). Subgroup analysis by surgery type indicated that bariatric (RR 0.20; 95% CI 0.068-0.578) and fundoplication procedures (RR 0.1; 95%CI 0.018-0.545) were associated with a substantial reduction in IHR. Moreover, totally-laparoscopic (T-LAP) procedures showed a significant reduction in IHR (RR 0.26;95%CI 0.14-0.5), while LAP-A procedures failed to show the same benefit.

CONCLUSION

LAP surgery is associated with reduced IHR in abdominal operations, with the benefit being particularly notable amongst LAP-A, bariatric, and fundoplication procedures. These findings underscore the advantages of LAP in specific surgical contexts, emphasizing its potential to minimize postoperative complications such as IH. Further research focusing on comparing IHR on open versus LAP approaches is warranted.

STUDY REGISTRATION

A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024551280).

Health Expenditures of Patients With Diabetes After Bariatric Surgery: Comparing Gastric Bypass and Sleeve Gastrectomy

BACKGROUND

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) differ in their effects on body weight and risk for reoperation. However, it is unclear whether long-term health expenditures differ by procedure type in patients with diabetes.

OBJECTIVE

To compare health expenditures 3 years before and 5.5 years after bariatric surgery between patients with diabetes undergoing RYGB versus SG.

DESIGN

Retrospective cohort study using target trial emulation principles.

SETTING

Integrated health system.

PATIENTS

Patients with diabetes undergoing RYGB (n = 3147) or SG (n = 3510) from 2012 to 2019.

MEASUREMENTS

Total, inpatient, outpatient, and medication expenditures.

RESULTS

Characteristics of patients undergoing RYGB and SG were well balanced after weighting; 73% were female, average body mass index was 43.8 kg/m2, and average age was 50 years. Expenditures per 6-month period decreased by about 30% for both groups, from $4039.06 (95% CI, $3770.88 to $4326.31) 3 years before to $2441.13 (CI, $2151.07 to $2770.30) 5.5 years after RYGB and from $3918.37 (CI, $3658.75 to $4196.40) 3 years before to $2658.15 (CI, $2279.17 to $3100.16) 5.5 years after SG. Total expenditures after surgery did not differ between groups through 5.5 years (difference at 5.5 years, -$217.02 [CI, -$671.29 to $201.96]) except for the first 6 months, when expenditures were transiently higher in the RYGB group (difference, $564.32 [CI, $232.60 to $895.20]), driven by a higher inpatient admission rate. Otherwise, postsurgical outpatient and medication expenditures did not appear to differ between RYGB and SG.

LIMITATION

Unobserved confounding.

CONCLUSION

Overall expenditures decreased substantially in the postsurgical period, primarily due to reductions in pharmacy expenditures, with no differences between RYGB and SG except in the first 6 months after surgery.

PRIMARY FUNDING SOURCE

National Institute of Diabetes and Digestive and Kidney Diseases.

Health Expenditures After Bariatric Surgery: A Retrospective Cohort Study

OBJECTIVE

To compare expenditures between surgical and matched nonsurgical patients in a retrospective cohort study.

BACKGROUND

Bariatric surgery leads to substantial improvements in weight and weight-related conditions, but prior literature on postsurgical health expenditures is equivocal.

METHODS

In a retrospective study, total outpatient, inpatient, and medication expenditures 3 years before and 5.5 years after surgery were compared between 22,698 bariatric surgery [n = 7127 Roux-en-Y gastric bypass (RYGB), 15,571 sleeve gastrectomy (SG)] patients from 2012 to 2019 and 66,769 matched nonsurgical patients, using generalized estimating equations. We also compared expenditures between patients receiving the 2 leading surgical procedures in weighted analyses.

RESULTS

Surgical and nonsurgical cohorts were well matched, 80% to 81% females, with mean body mass index of 44 and mean age of 47 (RYGB) and 44 (SG) years. Estimated total expenditures were similar between surgical and nonsurgical groups 3 years before surgery ($27 difference, 95% CI: -42, 102), increased 6 months before surgery for surgical patients, and decreased below preperiod levels for both groups after 3 to 5.5 years to become similar (difference at 5.5 years = -$61, 95% CI: -166, 52). Long-term outpatient expenditures were similar between groups. Surgical patients' lower long-term medication expenditures ($314 lower at 5.5 years, 95% CI: -419, -208) were offset by a higher risk of hospitalization. Total expenditures were similar between patients undergoing RYGB and SG 3.5 to 5.5 years after surgery.

CONCLUSIONS

Bariatric surgery translated into lower medication expenditures than matched controls, but not lower overall long-term expenditures. Expenditure trends appear similar for the two leading bariatric operations.

Trends and Outcomes of Laparoscopic Surgery in Low-Resource Settings: Lessons From Two African Healthcare Systems-A Narrative Review

Introduction

Laparoscopic surgery (LS) has been a promising development in surgical practice globally ever since its introduction. LS has exhibited many an advantage, including bettering patient outcomes, lowering the risk of postoperative infection, and displaying economical affluence. However, its implementation in the African continent still faces various challenges. In this review, we investigated the status of laparoscopic surgery integration in Africa.

Objectives

In this review, we aimed to investigate the challenges posed by the implementation of LS in low resource countries as well as critically evaluating initiatives and their impact within said domiciles. We also provide recommendations that may assist in LS prosperity in these settings by focusing efforts on improving training and financial incentives.

Methods

A comprehensive literature review was conducted to garner up-to-date evidence concerning the fate of LS adoption in low- to middle-income countries. This comprised the analysis of different case studies from countries including Nigeria and Botswana, and investigated relevant recommendations and policies provided by other African countries.

Results

Various challenges face the implementation of LS in countries with low resources comprising poor infrastructure, scarce training programs, and expert training personnel alongside financial boundaries. The adoption of LS in Africa has proved its benefits in improving patient outcomes and reducing hospital admissions. From a perspective of policy, it is crucial to sustain strong ties amongst institutions, stressing the importance of dynamic collaboration and locally tailored policies.

Conclusion

It has been demonstrated that LS implementations in African nations lower infection rates and expedite recovery. A strong collaboration between governments, stakeholders, and healthcare providers is fundamental for successful integration of LS. Such extension in low-resource environments may be achieved by providing proper training programs, funding infrastructure and equipment, and fostering effective financial initiatives.

Predictors of postoperative bleeding after minimally invasive bariatric surgery

BACKGROUND

Minimally invasive bariatric surgeries provide effective weight loss with fewer complications. However, postoperative bleeding remains a significant concern due to its potential for serious morbidity and mortality. This study aimed to identify factors predicting postoperative bleeding following laparoscopic and robotic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

METHODS

We analyzed patients who underwent SG and RYGB using the MBSAQIP database from 2015 to 2021. Four multivariate logistic regression analyses were conducted to investigate the relationship between postoperative bleeding and 24 independent factors for laparoscopic SG (lapSG), robotic SG (rSG), laparoscopic RYGB (lapRYGB), and robotic RYGB (rRYGB).

RESULTS

We analyzed 659,294 lapSG, 53,548 rSG, 267,171 lapRYGB, and 22,492 rRYGB patients. In lapSG, the most significant factors included anticoagulation (OR 3.76; 95% CI 3.13-4.51), renal insufficiency (OR 2.06; 95% CI 1.37-3.09), history of DVT (OR 1.87; 95% CI 1.23-2.85), history of PE (OR 1.69; 95% CI 1.04-2.76, and BMI ≤ 40 (OR 1.22; 95% CI 1.09-1.38). In the rSG group, anticoagulation (OR 4.95; 95% CI 2.83-8.66), COPD (OR 2.80; 95% CI 1.29-6.05), and hyperlipidemia (OR 1.90; 95% CI 1.29-6.05) were significant factors. In lapRYGB, the most significant factors included anticoagulation (OR 3.68; 95% CI 3.11-4.35), renal insufficiency (OR 1.60; 95% CI 1.04-2.44), history of DVT (OR 1.70; 95% CI 1.09-2.07), cardiac stent (OR 1.51; 95% CI 1.09-2.07), and BMI ≤ 40 (OR 1.16; 95% CI 1.03-1.29). For rRYGB, anticoagulation (OR 4.69; 95% CI 2.86-7.70), history of PE (OR 4.28; 95% CI 1.53-12.00), and cardiac stent (OR 2.15; 95% CI 0.06-4.34) were significant.

CONCLUSION

Preoperative anticoagulation, renal insufficiency, history of DVT and PE, a cardiac stent, and BMI ≤ 40 are associated with an increased risk of postoperative bleeding. The predictive factors were consistent across laparoscopic and robotic approaches in SG and RYGB procedures.

A Systematic Review to Summarise and Appraise the Reporting of Surgical Innovation: a Case Study in Robotic Roux-en-Y Gastric Bypass

Robotic Roux-en-Y gastric bypass (RRYGB) is an innovative alternative to traditional laparoscopic approaches. Literature has been published investigating its safety/efficacy; however, the quality of reporting is uncertain. This systematic review used the Idea, Development, Exploration, Assessment and Long-term follow-up (IDEAL) framework to assess the reporting quality of available literature. A narrative summary was formulated, assessing how comprehensively governance/ethics, patient selection, demographics, surgeon expertise/training, technique description and outcomes were reported. Forty-seven studies published between 2005 and 2024 were included. There was incomplete/inconsistent reporting of governance/ethics, patient selection, surgeon expertise/training and technique description, with heterogenous outcome reporting. RRYGB reporting was poor and did not align with IDEAL guidance. Robust prospective studies reporting findings using IDEAL/other guidance are required to facilitate safe widespread adoption of RRYGB and other surgical innovations.

Robotic versus laparoscopic gastric bypass in bariatric surgery: a systematic review and meta-analysis on perioperative outcomes

BACKGROUND

Robotic-assisted surgery has emerged as a compelling approach to bariatric surgery. However, current literature has not consistently demonstrated superior outcomes to laparoscopic bariatric surgery to justify its higher cost. With its mechanical advantages, the potential gains from the robotic surgical platform are likely to be apparent in more complex cases such as gastric bypass, especially revisional cases.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize the literature and evaluate the peri-operative outcomes of patients with obesity undergoing robotic gastric bypass versus laparoscopic gastric bypass surgery.

SETTING

Systematic review.

METHODS

A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing outcomes of robotic and laparoscopic gastric bypass for obesity were included.

RESULTS

Twenty-eight eligible studies comprised a total of 82,155 patients; 9051 robotic bypass surgery (RBS) versus 73,104 laparoscopic bypass surgery (LBS) were included. All included studies compared Roux-en-Y gastric bypass. RBS was noted to have higher reoperation rate within 30 days (4.4% versus 3.4%; odds ratio 1.31 [95% CI, 1.04-1.66]; P = .027; I2 = 43.5%) than LBS. All other endpoints measured (complication rate, anastomotic leak, anastomotic stricture, surgical site infections, hospital readmission, length of stay, operative time, conversion rate and mortality) did not show any difference between RBS and LBS.

CONCLUSION

This systematic review and meta-analysis showed that there was no significant difference in key outcome measures in robotic versus laparoscopic gastric bypass. RBS was associated with a slightly higher reoperation rate and there was no reduction in overall complication rate with the use of robotic platform.

Internal post-bariatric hernia due to hepatic adhesion: a case report

Roux-en-Y gastric bypass, a procedure proven effective for treating morbid obesity and metabolic disorders, carries the risk of complications such as the formation of internal hernias. These hernias are often difficult to diagnose and can be potentially fatal because they can cause structural obstruction. Most internal hernias occur in the jejunojejunostomy mesentery space, followed by Petersen's space hernias, although herniation at other locations can also occur. Our case report presents an example of a rare internal hernia after laparoscopic Roux-en-Y gastric bypass. A 36-year-old woman presented with an uncommon internal hernia located between the liver and alimentary loop, resulting in the formation of a new space and consequently incarcerating the entire biliopancreatic loop. This type of internal hernia is rare and has not been reported in the literature, indicating that this is the first report of such a case. In this case, we realized that the diagnosis was challenging and imaging examinations could not help determine the etiology of the pain and obstruction. Therefore, videolaparoscopy revealed an uncommon hernia formed by firm adhesion between the hepatic segment III and the alimentary loop mesentery. Our case is an example of an internal hernia that was not detected with a normal computed tomography scan of the abdomen and pelvis. Only diagnostic laparoscopy revealed herniation, effectively preventing further complications for the patient.

Clinical and economic comparative analysis of laparotomy versus laparoscopy in the first gastric bypass surgeries in a bariatric and metabolic surgery service in a city in southern Brazil

INTRODUCTION

this paper aims to evaluate the main direct and indirect costs of the first laparotomies and laparoscopies in bariatric surgeries with a clinical-economical retrospective and cross-sectional analysis from 2017 to 2020 at a hospital with specialties besides the basic ones in southern Brazil.

METHODS

the study sample included 26 participants. The first 13 laparotomies, and the first 13 laparoscopies performed at the bariatric surgery service of the institution were evaluated. The values evaluated in such comparison analyzed the costs of operation and hospitalization. It is important to highlight that, in addition to the cost benefit, other costs take significance in the health area, such as: cost-utility, cost-effectiveness and cost-minimization, in addition to the cost-opportunity that is reassessed in the observation of the broad context associating all the values raised here. The software used for data analysis was Excel version® 365. The economic analysis was performed evidencing the profile of the patients and the direct and indirect costs involved in each segmentation.

RESULTS

the direct and indirect costs of videolaparoscopy amounted to BRL 10,108.10 and laparoscopy to the amount of BRL 12,568.14.

CONCLUSION

it was concluded that laparoscopy presents more savings in the aspects of all health valuations to the detriment of laparotomy. It was concluded that the videolaparoscopy presents more savings in the aspects of all health valuations than the laparotomy.

LAPAROSCOPIC AND LAPAROTOMY BARIATRIC SURGERY IN A PUBLIC HOSPITAL IN BRAZIL: ARE THERE DIFFERENCES IN COSTS AND COMPLICATIONS?

BACKGROUND

Despite its increasing popularity, laparoscopy is not the option for bariatric surgeries performed in the Brazilian public health system.

AIMS

To compare laparotomy and laparoscopic access in bariatric surgery, considering aspects such as morbidity, mortality, costs, and length of stay.

METHODS

The study included 80 patients who were randomly assigned to perform a Roux-en-Y gastric bypass. They were equally divided in two groups, laparoscopic and laparotomy. The results obtained in the postoperative period were evaluated and compared according to the Ministry of Health protocol, and later, in their outpatient returns.

RESULTS

The surgical time was similar in both groups (p=0.240). The costs of laparoscopic surgery proved to be higher, mainly due to staplers and staples. The patients included in the laparotomy group presented higher rates of severe complications, such as incisional hernia (p<0.001). Costs related to social security and management of postoperative complications were higher in the open surgery group (R$ 1,876.00 vs R$ 34,268.91).

CONCLUSIONS

The costs related to social security and treatment of complications were substantially lower in laparoscopic access when compared to laparotomy. However, considering the operative procedure itself, the laparotomy remained cheaper. Finally, the length of stay, the rate of complications, and return to labor had more favorable results in the laparoscopic route.

Effect of operative times in bariatric surgery on outcomes: a matched analysis of the MBSAQIP database

BACKGROUND

The implications of operative time (OT) have been studied in different surgical specialties, showing a correlation with higher incidence rates of postoperative complications. However, the impact of OT on bariatric surgery complications is not well elucidated.

METHODS

A retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database between 2015 and 2019 was performed. A total of 358,382 SG patients and 123,357 RYGB patients were included. The median OT was 68 min (10-720) and 113 min (10-640) for the sleeve gastrectomy (SG) group and the Roux-en-Y gastric bypass group, respectively. The groups were subdivided into two subgroups based on OT in comparison to the median time of each group. The subgroups were compared for surgical complications and outcomes. To reduce selection bias and risk of confounders, we performed a propensity score matching (PSM) for 22 variables.

RESULTS

In the PSM-matched cohort, 18,915 SG and 6,495 RYGB patients were included in each subgroup. The SG cohort showed higher rates of Clavien-Dindo Class 1, 2, 3a, 4, and 5 complications as well as higher rates of readmission, reoperation, and reintervention in the longer OT group before matching. After PSM, the subgroup with longer times continued to have higher rates of Clavien-Dindo Class 2 complications and higher rates of readmission and reoperation. Similarly, there were higher rates of all Clavien-Dindo class complications as well as readmission, reoperation, and reintervention in the RYGB group with higher OT. After PSM, there were still higher rates of Clavien-Dindo Class 3a complications as well as readmission and reintervention in the RYGB subgroup with prolonged OT.

CONCLUSION

In both SG and RYGB, longer OT was associated with increased rates of complications as well as readmission, reoperation, and reintervention. Surgeons should be cognizant of the increased rates of complications when operative times are longer.

[The first experience of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity]

OBJECTIVE

To study the results of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity.

MATERIAL AND METHODS

A prospective cohort study included 74 patients who underwent bariatric surgery (Senhance digital laparoscopy system) between January 2022 and May 2023. Of these, 12 patients underwent robot-assisted longitudinal gastrectomy, 20 patients - robot-assisted Roux-en-Y gastric bypass, 36 patients - robot-assisted gastric bypass with one anastomosis/mini-gastric bypass, 6 patients - surgical exploration. We assessed duration of surgery, docking, placement of trocars and robotic manipulators, the need for their intraoperative displacement, incidence of intraoperative complications and conversions to laparoscopic surgery, intraoperative blood loss and early postoperative complications, severity of pain syndrome on the 1st day after surgery.

RESULTS

Mean surgery time was 87 [67, 120], 116 [78, 139], 96 [79, 125] and 141 [112, 184] min, respectively. Intraoperative blood loss was less than 50 ml. There were no complications requiring surgical treatment, cardiovascular, respiratory and other complications within 1 month.

CONCLUSION

Robot-assisted bariatric surgery using the Senhance system is feasible and safe for patients. Immediate results of robotic surgery are comparable to those after laparoscopy. However, large experience and cost-effectiveness analysis are required to assess the feasibility of robotic systems in bariatric surgery.

Excess visceral fat area as an independent risk factor for early postoperative complications in patients with obesity undergoing bariatric surgery

BACKGROUND

Few studies have investigated the correlation between visceral fat area (VFA) and early postoperative complications in patients with obesity undergoing bariatric surgery. This study aimed to investigate the relationship between VFA and early postoperative complications in patients with obesity following bariatric surgery.

METHODS

The study was conducted at a tertiary university hospital. Patients with obesity who underwent laparoscopic sleeve gastrectomy between June 2016 and October 2020 were divided into two groups based on umbilical level VFA: high-VFA group (umbilical level VFA ≥ 100 cm²) and low-VFA group (umbilical level VFA < 100 cm²). Baseline characteristics, intraoperative and postoperative conditions, and early postoperative complications were compared between the groups. The primary outcome was early postoperative complications, and the secondary outcome was postoperative hospital stay.

RESULTS

The study included 152 patients, with 82 patients in the low-VFA group and 70 patients in the high-VFA group. The high-VFA group had a higher incidence of early postoperative complications (14.29% vs. 2.44%, P = 0.013) than the low-VFA group. The length of postoperative hospital stay did not differ significantly between the groups.

CONCLUSIONS

Our study suggests that excess VFA is an independent risk factor for early postoperative complications following bariatric surgery, and VFA may be used in preoperative evaluations.

Outcome and quality of life in obese patients underwent laparoscopic vs. open appendectomy

Background

Although obesity is a popular reason for choosing laparoscopic appendectomy (LA) versus open appendectomy (OA), however, the question of whether there is a difference remains. Our goal is to investigate if there is a difference between OA and LA in obese patients.

Methods

Fifty-eight obese patients diagnosed with acute appendicitis according to ALVARDO score at department of surgery at Suez Canal university hospitals from March 2020 till August 2021 were included. The study participants were assigned in two groups LA and OA. This study aimed to comparing between LA and OA regarding intraoperative complications, length of hospital stays, post -operative pain, and rate of post-operative complications. Meanwhile, using SF-36 scoring questionnaire, the quality of life was compared between both groups.

Results

A total of 58 patients were included in the present study (LG = 29 patients and OG = 29 patients). The early post-operative complications (within 30 days after surgery) were significantly lower in the LA group (5 patients out of 29) than the OA (11 patients out of 29). Additionally, lower incidence of complications was noticed in the LA group (2 out of 29 patients) compared to OA (6 patients out of 29) beyond 30 days after operation. Patients with laparoscopic surgery had statistically significant higher overall quality of life scores (SF-36) (72 ± 32) compared to open surgery patients (66 ± 35) 2 weeks after operation.

Conclusion

The laparoscopic procedure was associated with lower incidence of post operative complications. However, open appendectomy was superior for a shorter operative time. Laparoscopic approach is not only used for therapeutic purposes, but also it has a diagnostic role.

Current Practices and Guidelines for Perioperative Blood Management in Post-Bariatric Body Contouring Surgery: A Comprehensive Review of Literature

With the increase in obesity prevalence, a noticeable increase in bariatric surgeries has been reported in national and international statistics. Therefore, body contouring surgeries have increased to help individuals achieve their desired body shape. Plastic surgeons need to consider potential hematologic complications that may occur in this specific group of patients before performing body contouring surgery. This review illustrates the perioperative medical, laboratory, and management strategies needed to minimize blood loss and blood transfusion requirements during body contouring. Using Google Scholar and PubMed, a comprehensive literature review was conducted to identify articles discussing post-bariatric body contouring perioperative blood management strategies, including the effects of bariatric surgery on hemostasis as well as basic hematology and coagulation. In preoperative blood management, blood investigations aid in the early detection of electrolytes, protein, and vitamin deficiencies and anemia, resulting in the early correction of nutritional deficiencies. In order to reduce postoperative complications, surgical and anesthesia techniques, as well as intraoperative pharmacological therapy, play an essential role. Postoperative blood transfusion and restrictive transfusion thresholds are tailored to the patient's needs and depend on various physiological indicators, such as heart rate, blood pressure, urine output, and laboratory findings, such as acidosis and hematocrit level. Generally, post-bariatric body contouring blood management measures are still lacking, and more research is required to develop standardized guidelines for optimizing patient safety and satisfaction.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Laparoscopic Versus Laparotomy Surgical Interventions for Trauma Patients With Single Upper Left Quadrant Penetrating Injuries: Analysis of the American College of Surgeons Trauma Quality Improvement Program Dataset

BACKGROUND

We aim to identify patient cohorts where laparoscopy can be safely utilized with comparable or better outcomes to laparotomy among patients with single penetrating LUQ injuries with a hypothesis that compared to laparotomy, laparoscopy may be associated with equal or improved outcomes of low injury severity patients.

METHODS

Retrospective review of the ACS-TQP-Participant Use File 2016-2019 dataset. Patients with single LUQ penetrating injuries were included. Primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included: risk-adjusted complication rates, hospital length-of-stay (H-LOS), and ICU-LOS. Descriptive statistics and multivariable regression with reliability adjustments to account for variations in practice were performed.

RESULTS

Of 4149 patients analyzed, 3571 (86.1%) underwent laparotomy, 489 (11.8%) underwent laparoscopy, and 89 (2.1%) underwent laparoscopy-to-laparotomy conversion. Adjusted mortality rates were not significantly different among all study cohorts (P > .05). Compared to laparoscopy, adjusted odds of complications were 4.3-fold higher for all patients who underwent laparotomy and 4-fold higher for laparoscopy-to-laparotomy (LtL) patients (P < .05). Diaphragmatic injuries were associated with significantly increased odds of undergoing LtL, whereas sustaining a colonic injury, gastric injury, hepatic injury, or requiring PRBC transfusions were associated with significantly increased odds of undergoing laparotomy (P < .05). H-LOS (days) was significantly longer for patients who underwent laparotomy compared to laparoscopy (3.9 ± 4.0 vs. 10.8 ± 13.4, P < .0001).

CONCLUSIONS

Laparoscopy may be considered a viable alternative to laparotomy for hemodynamically stable adult patients with single penetrating LUQ injuries of low injury burden validating our hypothesis. Laparoscopy may be less safe for patients with associated diaphragmatic, colonic, or hepatic injuries.

Plasma and Interstitial Fluid Pharmacokinetics of Prophylactic Cefazolin in Elective Bariatric Surgery Patients

Guidelines for surgical prophylactic dosing of cefazolin in bariatric surgery vary in terms of recommended dose. This study aimed to describe the plasma and interstitial fluid (ISF) cefazolin pharmacokinetics in patients undergoing bariatric surgery and to determine an optimum dosing regimen. Abdominal subcutaneous ISF concentrations (measured using microdialysis) and plasma samples were collected at regular time points after administration of cefazolin 2 g intravenously. Total and unbound cefazolin concentrations were assayed and then modeled using Pmetrics. Monte Carlo dosing simulations (n = 5,000) were used to define cefazolin dosing regimens able to achieve a fractional target attainment (FTA) of >95% in the ISF suitable for the MIC for Staphylococcus aureus in isolates of ≤2 mg · L-1 and for a surgical duration of 4 h. Fourteen patients were included, with a mean (standard deviation [SD]) bodyweight of 148 (35) kg and body mass index (BMI) of 48 kg · m-2. Cefazolin protein binding ranged from 14 to 36% with variable penetration into ISF of 58% ± 56%. Cefazolin was best described as a four-compartment model including nonlinear protein binding. The mean central volume of distribution in the final model was 18.2 (SD 3.31) L, and the mean clearance was 32.4 (SD 20.2) L · h-1. A standard 2-g dose achieved an FTA of >95% for all patients with BMIs ranging from 36 to 69 kg · m-2. A 2-g prophylactic cefazolin dose achieves appropriate unbound plasma and ISF concentrations in obese and morbidly obese bariatric surgery patients.

Comparative Safety of Sleeve Gastrectomy and Roux-en-Y: A Propensity Score Analysis

BACKGROUND

Use of bariatric surgery has increased dramatically in the USA. However, there are growing concerns regarding the safety outcomes of different bariatric procedures. We aim to compare the safety of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), which includes hospital readmissions, emergency room (ER) visits, gastrointestinal bleeding, and revisional surgery.

METHODS

A retrospective cohort analysis was conducted for adults (≥ 18 years) who received SG and RYGB in the USA. We used Truven MarketScan Commercial and Medicare supplemental claims databases from January 1, 2005, to October 1, 2015. To adjust for baseline demographic and clinical characteristics, we used stabilized inverse probability of treatment weighting using propensity score. Cox proportional hazard models was used to compare safety outcomes between SG and RYGB after bariatric surgery.

RESULTS

A total of 194,248 patients met inclusion criteria; 79,813 patients (41%) received SG and 114,435 patients (59%) received RYGB. The use of SG was associated with a significantly lower 30-day hospital readmission rate [adjusted hazard ratios (aHRs) 0.77; 95% confidence interval (CI), 0.74-0.81] and ER visits [aHR, 0.82; 95% CI, 0.80-0.83], and decreased risk of gastrointestinal bleeding [aHR, 0.87; 95% CI, 0.78-0.98] compared to RYGB. However, SG was associated with an increased risk of revisional surgery, compared to RYGB [aHR,1.21; 95% CI, 1.08-1.35].

CONCLUSIONS

Among patients receiving bariatric surgery in a real-world setting, SG was associated with lower complication rate but a higher risk of revisional surgery compared to RYGB. Further longitudinal studies are needed to assess long-term findings.

Towards interpretable, medically grounded, EMR-based risk prediction models

Machine-learning based risk prediction models have the potential to improve patient outcomes by assessing risk more accurately than clinicians. Significant additional value lies in these models providing feedback about the factors that amplify an individual patient's risk. Identification of risk factors enables more informed decisions on interventions to mitigate or ameliorate modifiable factors. For these reasons, risk prediction models must be explainable and grounded on medical knowledge. Current machine learning-based risk prediction models are frequently 'black-box' models whose inner workings cannot be understood easily, making it difficult to define risk drivers. Since machine learning models follow patterns in the data rather than looking for medically relevant relationships, possible risk factors identified by these models do not necessarily translate into actionable insights for clinicians. Here, we use the example of risk assessment for postoperative complications to demonstrate how explainable and medically grounded risk prediction models can be developed. Pre- and postoperative risk prediction models are trained based on clinically relevant inputs extracted from electronic medical record data. We show that these models have similar predictive performance as models that incorporate a wider range of inputs and explain the models' decision-making process by visualizing how different model inputs and their values affect the models' predictions.

Linear Versus Circular Laparoscopic Gastrojejunal Anastomosis of Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis of 22 Comparative Studies

PURPOSE

To compare the rate of complications of linear versus circular gastrojejunal anastomosis of laparoscopic Roux-en-Y gastric bypass.

METHODS

A systematic search of PubMed, Embase, and the Cochrane Library databases was carried out using the terms "laparoscopic," "circular," "linear," "anastomosis," "gastric bypass" in accordance to PRISMA guidelines. Only original articles in English language comparing linear versus circular anastomosis were included. No temporal interval was set. Outcome measures were wound infection, bleeding, marginal ulcer, leak, and stricture. Pooled odds ratio (OR) with a 95% confidence interval (CI) was calculated. Heterogeneity was assessed using the I2 statistic. Funnel plots were used to detect publication bias.

RESULTS

Twenty-two articles (7 prospective and 15 retrospective) out of 184 retrieved papers were included in this study. The pooled analysis showed a reduced odd of wound infection and bleeding after linear anastomosis. Likelihood of marginal ulcer, leak, and stricture was similar after the 2 techniques. Wound infection was reported in 15 studies (OR, 0.17; 95% CI, 0.06-0.45; P=0.0003; I2=91), bleeding in 9 (OR, 0.45; 95% CI, 0.34-0.59; P=0.00001; I2=6) marginal ulcer in 11 (OR, 0.61; 95% CI, 0.26-1.41; P=0.25; I2=65), leaks in 15 (OR, 0.61; 95% CI, 0.21-1.67; P=0.34; I2=83) and stricture in 18 (OR, 0.48; 95% CI, 0.23-1.00; P=0.05; I2=68).

CONCLUSION

Laparoscopic RYGB can be safely performed both with circular and linear staplers. Rates of wound infection and bleeding were significantly lower after linear gastrojejunal anastomosis.

Ertapenem Concentrations in Obese Patients Undergoing Surgery

Background: Antimicrobial prophylaxis is a cornerstone to preventing surgical site infections (SSIs). Ertapenem, a carbapenem antibiotic, is commonly used for surgical prophylaxis for many different procedures, including patients undergoing colorectal and other gastrointestinal surgeries. Obesity complicates surgical intervention and increases the risk for SSIs. This study aims to describe the pharmacokinetics of ertapenem for surgical prophylaxis using a population pharmacokinetic model. Patients and Methods: Ten patients were recruited and given a single dose of ertapenem 1 g intravenous over 30 minutes. Plasma samples were obtained at multiple time points over 24 hours and assayed via validated high-performance liquid chromatography (HPLC). Pharmacokinetic analyses were conducted using a population pharmacokinetic analysis to generate pharmacokinetic parameters used in the subsequent 5,000 patient Monte Carlo simulation. The probability of target attainment (PTA) for free drug concentrations remaining above the minimum inhibitory concentration (MIC) for ≥40% was used. Results: The mean maximum plasma concentration and area under the concentration time curve (AUC_0-∞) was 40.7 ± 16.5 and 148.8 ± 28.0, respectively, with a half-life of the terminal portion to be 4.3 ± 0.8 hours. Monte Carlo simulations observed PTAs above 90% for MICs ≤0.25 and ≤0.125 mcg/mL in surgeries up to three and four hours, respectively. Sufficiently high PTAs were not attainable for MICs of ≥0.5 mcg/mL. Conclusions: Ertapenem given as 1 g single dose may be an appropriate candidate for surgical prophylaxis in obese patients undergoing surgeries of four hours or less.

Abdominal Wall Thickness at Palmer's Point and Distance to Adjacent Structures Across the Body Mass Index Spectrum

STUDY OBJECTIVE

Studies delineating left upper quadrant (LUQ) anatomy across a range of body mass indices are lacking. We aimed primarily to compare, between non-obese and obese women, abdominal wall thickness and the distance from the LUQ to key structures. Additionally, we aimed to characterize LUQ anatomy in underweight women.

DESIGN

A retrospective cohort study.

SETTING

A tertiary academic medical institution.

PATIENTS

Sixty women (30 non-obese, 30 obese) age 18 and older who underwent abdominal imaging from 10/1/2018 through 12/31/2018.

INTERVENTIONS

Computed tomography imaging of the chest, abdomen, and pelvis.

MEASUREMENTS AND MAIN RESULTS

Abdominal wall thickness at the LUQ was significantly greater in obese (4.3 ± 1.7 cm) as compared to non-obese patients (2.4 ± 1.7 cm) (p<.001), as were distances to all key structures (aorta, vena cava, spleen, stomach, pancreas, liver, left kidney, pelvis) (p≤.02). On average, all structures, with the exception of stomach and liver, were >10 cm (the length of a typical insufflation needle) away from the LUQ insertion point in obese women. In underweight women, the aorta, spleen, stomach, pancreas, and liver were all within 10 cm of the LUQ insertion point. Within the obese and non-obese group, abdominal wall thickness at the LUQ was significantly greater than at the umbilicus (p<.001). Body mass index (BMI) was more strongly correlated with abdominal wall thickness at the LUQ (r=0.84, p<.001) than at the umbilicus (r=.69, p<.001) (p=.007 for comparison).

CONCLUSION

This study highlights special anatomic considerations for LUQ access in obese and underweight patients. In obese women, abdominal wall thickness may be greater at this site than at the umbilicus and the liver and stomach remain within reach of an insufflation needle. The increased working distance from the LUQ to the pelvis in obese patients may necessitate specialized instruments if this site is used during surgery. In underweight women, the aorta, in addition to many other structures, is within reach of commonly used entry devices.

A comparative evaluation of robotic and laparoscopic Roux-en-Y gastric bypass: a critical evaluation on the impact of postoperative pain and opioid requirements

INTRODUCTION

The benefits of minimally invasive surgery using laparoscopy on postoperative pain and opioid use are well established. Our goal was to determine whether patients who underwent Roux-en-Y gastric bypass using a robotic approach (RA-RYGB) had lower postoperative pain and required less opioids than those undergoing laparoscopic Roux-en-Y gastric bypass (L-RYGB). Secondary outcomes evaluated included length of stay, operative time, and readmissions.

METHODS AND PROCEDURES

This was a retrospective cohort study from a tertiary academic medical center. Patients who underwent L-RYGB or RA-RYGB between 5/1/2018 and 10/31/2019 were included. Cases with concomitant hernia repair, chronic opioid use, and those who did not receive a TAP block or multimodal pain control were excluded. Baseline demographics were compared. Inpatient and outpatient opioid use in Morphine Milligram Equivalents (MME) and pain scores (10-point Likert scale) were compared.

RESULTS

There were 573 RY patients included (462 L-RYGB; 111 RA-RYGB). Median and maximum inpatient pain scores were similar for L-RYGB and RA-RYGB (3.0 vs 3.1, p = 0.878; 7.0 vs 7.0, p = 0.688). Median inpatient opioid use and maximum single day use were similar for L-RYGB and RA-RYGB (40.0 MME vs. 42.0 MME, p = 0.671; 30.0 MME vs 30.0 MME, p = 0.648). Both the outpatient prescribing of opioids (50.2% vs. 42.3%, p = 0.136) and outpatient opioid MME at 2 weeks (L-RYGB 30.0 MME vs. 33.8 MME, p = 0.854) were comparable between cohorts. Patient reported pain at 2-week follow-up was significantly higher for RA-RYGB (68.1%) than L-RYGB (55.6%) (p = 0.030). RA-RYGB had a higher rate of 30-day readmission and longer operative times compared to the L-RYGB (6.3% vs 13.5%, p = 0.010; 144.5 vs 200.0 min, p < 0.001).

CONCLUSION

This study identified no benefit for postoperative pain or opioid requirements in patients undergoing RA-RYGB compared to L-RYGB. The RA-RYGB group was significantly more likely to report pain at the two-week follow-up.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

The SAGES MASTERS program presents the 10 seminal articles for Roux-en-Y gastric bypass

BACKGROUND

One of the eight clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program is bariatric surgery which includes three anchoring procedures. For each anchoring procedure sentinel articles have been identified to enhance participant surgeon lifelong learning. Roux-en-Y gastric bypass (RYGB) is one of the 3 anchoring procedures for the Bariatric Pathway. In this article we present the top 10 seminal articles regarding the RYGB which surgeons should be familiar with.

METHODS

The literature was systematically searched to identify the most cited papers on RYGB. The SAGES Metabolic and Bariatric Surgery committee reviewed the most cited article list and using expert consensus selected the seminal articles that every bariatric surgeon should read. These articles were reviewed in detail by committee members and are presented here.

RESULTS

The top 10 most cited sentinel papers on RYGB focus on operative safety, outcomes, surgical technique, and physiologic changes after the procedure. A summary of each paper is presented here, including expert appraisal and commentary.

CONCLUSION

The seminal articles presented here have supported the widespread acceptance and use of the RYGB 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.

Metabolic surgery in treatment of obese Japanese patients with type 2 diabetes: a joint consensus statement from the Japanese Society for Treatment of Obesity, the Japan Diabetes Society, and the Japan Society for the Study of Obesity

Bariatric surgery has been shown to have a variety of metabolically beneficial effects for patients with type 2 diabetes (T2D), and is now also called metabolic surgery. At the 2nd Diabetes Surgery Summit held in 2015 in London, the indication for bariatric and metabolic surgery was included in the “algorithm for patients with type T2D”. With this background, the Japanese Society for Treatment of Obesity (JSTO), the Japan Diabetes Society (JDS) and the Japan Society for the Study of Obesity (JASSO) have formed a joint committee to develop a consensus statement regarding bariatric and metabolic surgery for the treatment of Japanese patients with T2D. Eventually, the consensus statement was announced at the joint meeting of the 38th Annual Meeting of JSTO and the 41st Annual Meeting of JASSO convened in Toyama on March 21, 2021. In preparing the consensus statement, we used Japanese data as much as possible as scientific evidence to consider the indication criteria, and set two types of recommendation grades, “recommendation” and “consideration”, for items for which recommendations are possible. We hope that this statement will be helpful in providing evidence-based high-quality care through bariatric and metabolic surgery for the treatment of obese Japanese patients with T2D.

The Assessment of Food Addiction and the Yale Food Addiction Scale in Bariatric Surgery Populations

Food addiction (FA) appears among bariatric weight loss surgery candidates who struggle to control the intake of hyperpalatable/refined foods have high rates of psychopathology and related health problems. Despite this, prevalence rates of FA in the bariatric sector are reported as low or variable. We investigated the prevalence of FA and the applicability of conventionally used metrics for 166 pre-surgery candidates from a weight management centre (USA) and a major metropolitan hospital (Australia). Self-report measures assessed FA (Yale Food Addiction Scale (YFAS)), body mass index (BMI), disordered eating, addictive personality, psychopathology, and diet. Consistent with prior research, standard YFAS scoring, requiring the endorsement of a distress/impairment (D/I) criterion (FA + D/I), yielded a FA prevalence rate of 12.7%, compared to 37.3% when D/I was omitted (FA − D/I). We compared profiles for those with FA using each scoring method against those ‘without’, who did not meet a minimum of three YFAS symptoms (non-FA ≤ 2). Both methods differentiated those with and without FA on addictive traits, disordered eating and hyperpalatable food consumption. Only FA + D/I differentiated markers of psychological distress or impairment, including depression, anxiety and quality of life. Results indicate a need for further FA research in bariatric settings.

Management of Postoperative Complications Following Bariatric and Metabolic Procedures

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.

Impact of Excess Body Weight on Postsurgical Complications

BACKGROUND

Obesity is considered a risk factor for postoperative complications as it can limit exposure to the operation field, thereby significantly prolonging surgery time. Obesity-associated comorbidities, such as low-grade systemic inflammation, impaired functional status, and type 2 diabetes, are independent risk factors for impaired anastomotic wound healing and nonsurgical site infections. If obesity itself is an independent risk factor for surgical complications remains controversial, but the reason for this is largely unexplored.

SUMMARY

A MEDLINE literature search was performed using the terms: "obesity," "excess body weight," and "surgical complications." Out of 65,493 articles 432 meta-analyses were screened, of which 25 meta-analyses were on the subject. The vast majority of complex oncologic procedures in the field of visceral surgery have shown higher complication rates in obese patients. Meta-analyses from the last 10 to 15 years with high numbers of patients enrolled consistently have shown longer operation times, higher blood loss, longer hospital stay for colorectal procedures, oncologic upper gastrointestinal (GI) procedures, and pancreatic surgery. Interestingly, these negative effects seem not to affect the overall survival in oncologic patients, especially in esophageal resections. A selection bias in oncologic upper GI patients may have influenced the results with higher BMI in upper GI cancer to be a predictor for better nutritional and performance status.

KEY MESSAGES

Contrary to bariatric surgery, only limited evidence indicated that site and type of surgery, the approach to the abdominal cavity (laparoscopic vs. open), institutional factors, and the type of perioperative care such as ERAS protocols may play a role in determining postsurgical complications in obese patients. The initial question remains therefore partially unanswered. Large nationwide register-based studies are necessary to better understand which aspects of obesity and its related comorbidities define it as a risk factor for surgical complications.

Gastrojejunocolic fistula: case report of a rare late complication of laparoscopic Roux-en-Y gastric bypass and review of the literature

INTRODUCTION

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is known as the weight loss surgery to which other bariatric procedures are compared. While morbidity and mortality of this procedure are low, serious complications do exist which can be life-threatening and sometimes require surgical correction.

CASE PRESENTATION

A 63-year-old woman underwent LRYGB outside of the United States, later complicated by biliary colic treated with cholecystectomy and upper gastrointestinal bleeding secondary to H. pylori-related ulcer at her gastrojejunostomy. Following adequate treatment of the patients marginal ulcer, the patient experienced several months of progressive severe abdominal pain, frequent vomiting and diarrhea, and unintentional weight loss refractory to pharmacologic therapy. The patient underwent multiple medical and endoscopic evaluations unrevealing of an organic cause of her symptoms. At presentation, the patient was found to be profoundly weak, dehydrated and malnourished with metabolic derangements and was subsequently diagnosed with a gastrojejunocolic fistula via upper endoscopy and radiography. We provided excluded stomach gastrostomy tube feeding to the patient for three months to improve the patients nutritional status before definitive surgical correction was successfully performed.

DISCUSSION

Large bowel fistulas are a rare and highly morbid late complication following LRYGB and are likely secondary to marginal ulcers and/or instrumentation such as endoscopy. Surgery represents the definitive treatment.

CONCLUSION

LRYGB is typically a safe and effective intervention for obesity. Large bowel fistulas are rare complications following this surgery. We highlight difficulties in diagnosing and treating this condition.

Small Bowel Obstruction After Laparoscopic Roux-en-Y Gastric Bypass Caused by Hemobezoar: A Case Series and Review of Literature

BACKGROUND

The development of an intraluminal blood clot (hemobezoar), represents a rare cause (0.05% to 1.9%) of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). We present a case series of 6 cases of SBO caused by hemobezoar.

METHODS

A retrospective analysis of a prospective database including patients who underwent LRYGB from January 2010 to December 2019 has been performed. All the patients who underwent reoperation because of an SBO caused by an intraluminal blood clot were included in the present study.

RESULTS

Six of 843 LRYGB patients developed an hemobezoar (0.71%). Primary LRYGB was uneventful in all cases. SBO symptoms developed after a mean interval of 26.6 hours from the primary procedure. All reoperations were performed with the laparoscopic approach. In all cases, the hemobezoar was located at the level of the jejunojejunal anastomosis (JJA) and was removed through an enterotomy performed at the distal end of the biliopancreatic stump. Three postoperative complications occurred: 1 ab-ingestis pneumonia, 1 leak of the JJA requiring further reoperation, and 1 pelvic abscess treated with radiologic drainage. The mean hospital stay was 11 days.

DISCUSSION

SBO due to hemobezoar is a rare but worrisome early complication after LRYGB. It almost always affects the JJA and requires a prompt diagnosis to avoid dreadful sequelae. In the absence of anastomotic leak or stenosis, surgical management may consist of the removal of the blood clot without refashioning the anastomosis and it may be accomplished with the laparoscopic approach.

Preventing Peterson's space hernia using a BIO synthetic mesh

Background

Internal hernias occur after Roux-en-Y gastric bypass surgery (RYGB) when small bowel herniates into the intermesenteric spaces that have been created. The closure technique used is related to the internal hernia risks outcomes. Using a non-resorbable double layered suture, this risk can be significantly reduced from 8.9 to 2.5% in the first three postoperative years. By closing over a BIO mesh, the risk might be reduced even more.

Setting

Two large private hospitals specialized in bariatric surgery.

Methods

All patients receiving a RYGB for (morbid) obesity between 2014 and 2018 were included in this retrospective study. In all patients, the entero-enterostomy (EE) was closed using a double layered non-absorbable suture. In 2014, Peterson’s space was closed exclusively using glue, the years hereafter in a similar fashion as the EE, combined with a piece of glued BIO Mesh.

Results

The glued RYGB patients showed 25% of patients with an internal hernia (14%) or open Peterson’s space compared to 0.5% of patients (p < 0.001) who had a combined sutured and BIO Mesh Closure of their Peterson’s space defect. Although this was an ideal technique for Peterson’s space, it led to 1% of entero-enterostomy kinking due to the firm adhesion formation.

Conclusion

Gluing the intermesenteric spaces is not beneficial but placing a BIO Mesh in Peterson’s space is a promising new technique to induce local adhesions. It is above all safe, effective and led to an almost complete reduction of Peterson’s internal herniations. In the future, a randomized controlled trial comparing this technique to a double layered, non-absorbable suture should give more insights into which is the optimal closure technique.

Global Variations in Practices Concerning Roux-en-Y Gastric Bypass-an Online Survey of 651 Bariatric and Metabolic Surgeons with Cumulative Experience of 158,335 Procedures

INTRODUCTION

There is significant variation in practices concerning Roux-en-Y gastric bypass (RYGB) among bariatric surgeons, but there is currently a lack of robust data on the nature and extent of these variations. The purpose of this study was to understand global variations in practices concerning RYGB.

METHODS

A questionnaire-based survey on Survey Monkey® was created, and the link was shared freely on various social media platforms. The link was also distributed through a personnel email network of authors.

RESULTS

A total of 657 surgeons from 65 countries completed the survey. Crohn's disease and liver cirrhosis were considered absolute contraindications for RYGB by 427 surgeons (64.98%) and 347 surgeons (53.30%), respectively. More than 68.5% of surgeons performed routine upper GI endoscopy while 64.17% performed routine ultrasound of abdomen preoperatively. The majority of surgeons (77.70%) used the perigastric technique for Gastric pouch creation. Approximately, 79.5% used orogastric bougie. More than 70% of the respondents did not use any staple line reinforcement routinely. Only 17.67% of surgeons measured the whole small bowel length, and the majority of surgeons (86.5%) used constant length of BP limb. Approximately, 89% used constant length of alimentary limb. Approximately, 95% of surgeons preferred antecolic bypass, and more than 86% routinely closed the Petersen defect. Marginal ulcer prophylaxis was used by the majority (91.17%). Almost 95% of surgeons recommended lifelong vitamin and mineral supplements.

CONCLUSION

This survey identifies global variations in practices concerning RYGB. It identifies several areas for future research and consensus building.

Chronic Abdominal Pain After Previous Bariatric Surgery: Consider the Abdominal Wall

BACKGROUND

Up to 30% of patients who undergo bariatric surgery experience recurrent abdominal pain within 3 years after the operation. Although some causes for persisting discomfort are well known, a small portion of patients may suffer from an abdominal wall pain associated with Anterior Cutaneous Nerve Entrapment Syndrome (ACNES). Aim of the present study is to discuss incidence, clinical presentation, and treatment outcome in patients with ACNES after bariatric surgery.

METHODS

This retrospective observational cohort study analyzed electronically stored data of patients with ACNES having a history of bariatric surgery. All were treated for ACNES between 2011 and 2017 in a Dutch center of excellence for abdominal wall and groin pain. Success after treatment was defined as a minimal 50% drop in pain level using a Numeric Rating Scale.

RESULTS

A total of 49 patients (female n = 44, median age 45 (25-63) years) were identified. Four (8%) experienced long-term pain relief after just one abdominal wall infiltration with lidocaine. Ten additional patients reported success after 2-5 injections. A total of 35 unresponsive patients chose to undergo a neurectomy that was successful in 27. Therefore, this step-up approach conferred an 84% success rate. Occurrence of ACNES after bariatric surgery was estimated at 1 in 100 patients.

CONCLUSION

ACNES should be considered in the differential diagnosis of ongoing pain following previous bariatric surgery. A treatment regimen including abdominal wall infiltrations using an anesthetic agent or a neurectomy is successful in a vast majority of these patients.

The Longitudinal Efficiency of Robotic Surgery: an MBSAQIP Propensity Matched 4-Year Comparison of Robotic and Laparoscopic Bariatric Surgery

BACKGROUND

The objective of this study was to examine the MBSAQIP database to assess efficiency trends and perioperative outcomes in robotic bariatric surgery.

METHODS

Robotic (RA) and laparoscopic (L) sleeve gastrectomy (SG) and gastric bypass (RYGB) were compared using the 2015-2018 MBSAQIP Participant Use Data Files. Patients were propensity matched 1:1 based on sex, body mass index, assistant, and previous obesity or foregut surgery. A total of 93,802 patients were included.

RESULTS

Median operative times were significantly longer for both RA-SG (89 vs. 62 min; p < 0.0001) and RA-RYGB (141 vs. 105 min; p < 0.0001) compared with laparoscopic. Over the 4-year period, the difference in operative times (OR delta) between RA-SG and L-SG was unchanged while the difference in operative times between RA-RYGB and L-RYGB increased. Both robotic groups were significantly more likely to be readmitted (RA-SG p = 0.001, RA-RYGB p = 0.006). Robotic SG was more likely to have a reintervention (p = 0.018) and extended length of stay (LOS) (> 4 days) compared with laparoscopic (p = < 0.0002). No significant differences were noted in morbidity and mortality by approach.

CONCLUSIONS

Operative times were 30% longer for RA-SG and 25% longer for RA-RYGB when compared with laparoscopic. There was no significant improvement in OR delta for either RA-SG or RA-RYGB over the four years. Readmission rates were higher for both RA-SG and RA-RYGB. Robotic SG had a greater percentage of patients with extended LOS compared with laparoscopic. No evidence of improved efficiency for robotic bariatric surgery as defined by operative time or clinical outcomes was identified.

Learning Curves of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Bariatric Surgery: a Systematic Review and Introduction of a Standardization

BACKGROUND

The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG.

METHODS

A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected.

RESULTS

A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30-500 (RYGB) and 30-200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery.

CONCLUSIONS

Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30-70, 70-150, and up to 500 RYGB, and after 30-50, 60-100, and 100-200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.

Laparoscopic Gastric Bypass: Still the Gold Standard?

Roux-en-Y gastric bypass has been considered the gold standard bariatric procedure for decades. The surgical technique for Roux-en-Y gastric bypass and perioperative management for patients who undergo the procedure are still being improved for better clinical outcomes, shorter hospitalization, and faster return to normal activity. In the past 15 years there have been similar improvements and further development of novel surgical weight loss procedures. As data on other surgical alternatives emerge, the data need to be compared with Roux-en-Y gastric bypass to determine noninferiority. Further long-term investigations are needed to determine superiority of one bariatric procedure over another.

Diagnostic imaging in the diagnosis of acute complications of bariatric surgery

PURPOSE

The aim of study is to identify the frequency of acute complications and imaging findings at gastro-intestinal transit (GI) and computerised tomography (CT) in a group of obese patients who developed clinical suspicion of acute complications (painful and meteoric abdomen, nausea, vomiting, fever, intestinal blockage) in post bariatric surgery.

MATERIAL AND METHODS

We retrospectively review 954 obese patients who underwent bariatric surgery between 2013 and 2019. The study included 72 patients who developed clinical suspicion of acute complications (painful and meteoric abdomen, nausea, vomiting, fever, intestinal blockage) within 6 days of bariatric surgery of sleeve gastrectomy, gastric banding, gastric bypass with Roux loop confirmed by CT, and who underwent a gastrointestinal transit before the CT examination.

RESULTS

GI exam allowed visualisation of 58% of complications. Analysing the data for each surgical technique, 46 post-operative complications were found involve gastric banding. The most frequent was bandage migration (26 cases, 56 %), identified in all cases at GI transit and then confirmed on CT.

CONCLUSIONS

The study suggests that CT should be used to clarify all doubtful or clinically discordant GI transit exam results. The participation of a radiologist in qualification and post-operative evaluation is important for bariatric surgery patients.

Comparison of gastrojejunostomy techniques and anastomotic complications: a systematic literature review

BACKGROUND

There are several ways to perform the gastrojejunostomy (GJ) anastomosis in laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgeons typically use a variation of three techniques: Hand-sewn anastomosis (HSA), Linear stapled (LS) and Circular stapled anastomosis (CSA). The purpose of this literature review is to determine which of the GJ techniques, if any, is superior and results in the least amount of postoperative complications, with a specific focus on rates of marginal ulcers, postoperative bleeding, and strictures.

METHODS

PubMed, Embase, and Cochrane electronic databases were consulted for studies on LRYGB procedures utilizing a GJ anastomosis, from January 1, 2015 to December 31, 2019. Cochrane and PRISMA screening methods were used to select the studies.

RESULTS

Eleven studies published between 2015 and 2019 were selected and included 135,899 patients that underwent LRYGB with a GJ anastomosis. Sample sizes ranged from 114 to 49,331 patients. Four studies reported that CSA had statistically significant higher rates of marginal ulcers when compared to HSA and LS techniques. Three studies concluded that CSA had statistically significant higher rates of postoperative bleeding when compared to HSA and LS. Five studies observed that CSA had statistically significant higher rates of strictures when compared to HSA and LS techniques. There was no consensus whether HSA or LS was superior in terms of reduced postoperative complications.

CONCLUSION

This study revealed statistically significant increases in rates of postoperative bleeding, marginal ulcer, and strictures with the use of mechanical circular staplers at the GJ anastomosis in LRYGB. Based on our results, avoiding the use of mechanical circular staplers can result in fewer postoperative complications. Nevertheless, there are limitations to retrospective studies which may influence the results and therefore a randomized controlled trial directly comparing HSA, CSA, and LS should be performed to truly determine which technique is superior.

Global Benchmark Values for Laparoscopic Roux-en-Y-Gastric Bypass: a Potential New Indicator of the Surgical Learning Curve

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a technically demanding procedure. The learning curve of LRYGB is challenging and potentially associated with increased morbidity. This study evaluates whether a general laparoscopic surgeon can be safely trained in performing LRYGB in a peripheral setting, by comparing perioperative outcomes to global benchmarks and to those of a senior surgeon.

Methods

All consecutive patients undergoing primary LRYGB between January 2014 and December 2017 were operated on by a senior (A) or a trainee (B) bariatric surgeon and were prospectively included. The main outcome of interest was all-cause morbidity at 90 days. Perioperative outcomes were compared with global benchmarks pooled from 19 international high-volume centers and between surgeons A and B for their first and last 30 procedures.

Results

The 213 included patients had a mean all-cause morbidity rate at 90 days of 8% (17/213). 95.3% (203/213) of the patients were uneventfully discharged after surgery. Perioperative outcomes of surgeon B were all within the global benchmark cutoffs. Mean operative time for the first 30 procedures was significantly shorter for surgeon A compared with surgeon B, with 108.6 min (± 21.7) and 135.1 min (± 28.1) respectively and decreased significantly for the last 30 procedures to 95 min (± 33.7) and 88.8 min (± 26.9) for surgeons A and B respectively.

Conclusion

Training of a new bariatric surgeon did not increase morbidity and operative time improved for both surgeons. Perioperative outcomes within global benchmarks suggest that it may be safe to teach bariatric surgery in peripheral setting.

Effects of laparoscopic vs open abdominal surgery on costs and hospital readmission rate and its effect modification by surgeons' case volume

BACKGROUND

Laparoscopy provides a minimally invasive alternative to open abdominal surgery. Current data describing its association with hospital readmission and costs in relation to surgeon laparoscopic case volume is limited to smaller databases and subsets of operations.

METHODS

This retrospective cohort study of 23,285 adult abdominal operations from 2007 to 2015 compares 30-day readmission rate and costs between laparoscopic and open abdominal operations and examines effect modification by surgeon laparoscopic case volume. Outcomes were all-cause hospital readmission within 30 days after discharge and index hospital admission cost.

RESULTS

All-cause hospital readmission rates were significantly lower after laparoscopic abdominal operations compared with open operations (adjusted odds ratio [aOR] 0.56, 95% CI 0.46-0.69, p < 0.001) with a difference in readmission risk attributable to laparoscopic approach of - 4.0% (95% CI - 5.4 to - 2.6%) in complete-case analysis. Among surgeons with a high laparoscopic case volume, the estimated difference in readmission risk through laparoscopy was magnified (- 5.8%, 95% CI - 7.5 to - 4.1%) compared to low surgeon laparoscopic case volume (- 2.9%, 95% CI - 4.8 to -1.1%, p for interaction = 0.005). The estimated difference in costs of the index hospital admission attributable to laparoscopic approach was - $3869 (95% CI - $4200 to - $3538; adjusted incidence rate ratio 0.77, 95% CI 0.75-0.79, p < 0.001). Laparoscopy was followed by significantly lower rates of readmissions related to gastrointestinal (aOR 0.68, 95% CI 0.55-0.85, p = 0.001), wound complications (infection: aOR 0.33, 95% CI 0.23-0.47, p < 0.001; non-infectious: aOR 0.47, 95% CI 0.30-0.74, p = 0.001), and malignancy (aOR 0.68, 95% CI 0.55-0.85, p < 0.001). The findings remain robust after multiple imputation and sensitivity analyses.

CONCLUSIONS

Laparoscopy versus open abdominal surgery is associated with reduced hospital readmissions related to malignancy, gastrointestinal, and wound complications. Effect modification by higher laparoscopy case volume argues for continued proliferation of laparoscopy in abdominal surgeries.

Biliopancreatic Limb Obstruction Due to an Unexpected Variant of Internal Hernia After Roux-en-Y Gastric Bypass

Small bowel obstruction due to internal hernia (IH) is a well-known late complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). A reliable and immediate diagnosis of IH is important for optimal and timely management of patients with a history of LRYGB. Mesenteric defects that are created during a LRYGB include the following: (1) through the transverse mesocolon defect, (2) through the entero-enterostomy mesenteric defect, and (3) through the space between the mesentery of Roux limb and transverse mesocolon (Petersen's space). The aim of this case is to present an unusual variant of IH after LRYGB that was laparoscopically explored and treated.

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

Current bariatric surgical practice has developed from early procedures, some of which are no longer routinely performed. This review highlights how surgical practice in this area has developed over time.

RECENT FINDINGS

This review outlines early procedures including jejuno-colic and jejuno-ileal bypass, initial experience with gastric bypass, vertical banded gastroplasty and biliopancreatic diversion with or without duodenal switch. The role laparoscopy has played in the widespread utilization of surgery for treatment of obesity will be described, as will the development of procedures which form the mainstay of current bariatric surgical practice including gastric bypass, sleeve gastrectomy and adjustable gastric banding. Endoscopic therapies for the treatment of obesity will be described. By outlining how bariatric surgical practice has developed over time, this review will help practicing surgeons understand how individual procedures have evolved and also provide insight into potential future developments in this field.

A Case of Wernicke's Encephalopathy in a Pregnant Woman With a History of Sleeve Gastrectomy

Wernicke’s encephalopathy (WE) is a neurological complication of thiamine deficiency characterized by a triad of acute confusion, ataxia, and ophthalmoplegia. Even though it is most common in chronic alcoholism, an increase in prevalence has been reported recently due to the increased popularity of bariatric surgeries. WE is a known neurological complication after gastric bypass surgery but rarely reported after sleeve gastrectomy. We present a unique case of WE in pregnant women four months after sleeve gastrectomy.

Physiological correlates of cognitive load in laparoscopic surgery

Laparoscopic surgery can be exhausting and frustrating, and the cognitive load experienced by surgeons may have a major impact on patient safety as well as healthcare economics. As cognitive load decreases with increasing proficiency, its robust assessment through physiological data can help to develop more effective training and certification procedures in this area. We measured data from 31 novices during laparoscopic exercises to extract features based on cardiac and ocular variables. These were compared with traditional behavioural and subjective measures in a dual-task setting. We found significant correlations between the features and the traditional measures. The subjective task difficulty, reaction time, and completion time were well predicted by the physiology features. Reaction times to randomly timed auditory stimuli were correlated with the mean of the heart rate (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r = - 0.29$$\end{document}r=-0.29) and heart rate variability (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r = 0.4$$\end{document}r=0.4). Completion times were correlated with the physiologically predicted values with a correlation coefficient of 0.84. We found that the multi-modal set of physiology features was a better predictor than any individual feature and artificial neural networks performed better than linear regression. The physiological correlates studied in this paper, translated into technological products, could help develop standardised and more easily regulated frameworks for training and certification.

Obesity and appendicitis: Laparoscopy versus open technique

Objectives

The clinical results of obese patients who have undergone open or laparoscopic appendectomy, whether one technique is superior to the other is still not clearly known.In our study, we compared the clinical results of obese patients operated with laparoscopic or open technique for acute appendicitis.

Material and Methods

We performed retrospective analyses of patients operated for acute appendicitis between the dates of July 2016 and July 2019 at Istinye University Faculty of Medicine Bahcesehir Liv Training and Research Hospital and Liv Hospital Ankara. Of the 241 patients whose height and weight information was accessible, 57 had a body mass index of 30 kg/m2 or higher. Eighteen of these patients underwent open surgery while the other 39 underwent laparoscopic surgery. The primary result criterion was complication ratio. Secondary criteria were operation time and length of hospital stay.

Results

Upon comparison of laparoscopic and open techniques in terms of intraoperative-postoperative complications (p= 0.01), operation time (p= 0.02) statistically significant differences were found between the groups. However the mean length of hospital stay (p= 0.181) was similar in both groups.

Conclusion

In obese appendicitis patients, the laparoscopic technique proved to be superior to the open technique in criteria such as perioperative-postoperative complications, operation time, and etc. Length of hospital stay was determined to be similar between the groups.

Low-pressure pneumoperitoneum with deep neuromuscular blockade in metabolic surgery to reduce postoperative pain: a randomized pilot trial

BACKGROUND

For metabolic laparoscopic surgery, higher pressures up to 20 mmHg are often used to create a surgical field of sufficient quality. This randomized pilot study aimed to determine the feasibility, safety and tolerability of low intraabdominal pressure (IAP) and deep neuromuscular blockade (NMB) to reduce postoperative pain.

METHODS

In a teaching hospital in the Netherlands, 62 patients eligible for a laparoscopic Roux-en-Y gastric bypass (LRYGB) were randomized into one of four groups in a 2 × 2 factorial design: deep/moderate NMB and standard (20 mmHg)/low IAP (12 mmHg). Patient and surgical team were blinded. Primary outcome measure was the surgical field quality, scored on the Leiden-Surgical Rating Scale (L-SRS). Secondary outcome measures were (serious) adverse events, duration of surgery and postoperative pain.

RESULTS

62 patients were included. L-SRS was good or perfect in all patients that were operated under standard IAP with deep or moderate NMB. In 40% of patients with low IAP and deep NMB, an increase in IAP was needed to improve surgical overview. In patients with low IAP and moderate NMB, IAP was increased to improve surgical overview in 40%, and in 75% of these cases a deep NMB was requested to further improve the surgical overview. Median duration of surgery was 38 min (IQR34-40 min) in the group with standard IAP and moderate NMB and 52 min (IQR46-55 min) in the group with low IAP and deep NMB.

CONCLUSIONS

The combination of moderate NMB and low IAP can create insufficient surgical overview. Larger trials are needed to corroborate the findings of this study.

TRIAL REGISTRATION

Dutch Trial Register: Trial NL7050, registered 28 May 2018. https://www.trialregister.nl/trial/7050 .