Robotic-Assisted Surgery Results in a Shorter Hospital Stay Following Revisional Bariatric Surgery

BACKGROUND

Revisional surgery is rapidly growing within the field of bariatric surgery. The use of robotic assisted surgery, considered controversial by many, may offer advantages in revisional bariatric surgery (RBS). There are few studies comparing laparoscopic and robotic-assisted RBS. The aim of this study is to compare the safety and outcome of laparoscopic and robotic RBS in a single accredited center.

METHODS

A retrospective analysis of data collected prospectively on patients undergoing either laparoscopic (L-RBS) or robotic (R-RBS) RBS between January 1, 2017 and December 31, 2019 was performed. The primary outcomes included length of stay (LOS), 30-day major and minor complication rates, readmission rates, and mortality rates.

RESULTS

A total of 167 patients were included in our analysis. Fifty-two patients underwent R-RBS (31%), and 115 underwent L-RBS (69%). Thirty-day major and minor complication rates for R-RBS and L-RBS were 1.9% and 5.8% vs 5.2% and 5.2%, respectively (p > .05). There was no difference in readmission rates (3.8% vs 8.7%, p > 0.05) or intraoperative blood loss (35.5 mL vs 37.4 mL, p > .05) between R-RBS and L-RBS. R-RBS resulted in a shorter length of stay when compared with L-RBS (40.2 h vs 62.6 h, p < .05).

CONCLUSIONS

R-RBS has a decreased, albeit non-significant, rate of 30-day major complications with no difference in minor complications, readmission rates, or intraoperative blood loss when compared with L-RBS. R-RBS resulted in a decreased length of stay when compared with L-RBS. Randomized clinical trials are needed to better elucidate our findings.

Cost Analysis of Robotic Roux-en-Y Gastric Bypass in a Single Academic Center: How Expensive Is Expensive?

BACKGROUND

Although the use of da Vinci robotic platforms in bariatric surgery is gaining momentum, it is still controversial because of financial concerns.

OBJECTIVES

The objective of our study is to evaluate the cost of robotically assisted Roux-en-Y gastric bypass (R-RYGB) versus conventional laparoscopic Roux-en-Y gastric bypass (L-RYGB).

METHODS

We analyzed consecutive primary bariatric patients who underwent R-RYGB and compared them with patients who underwent L-RYGB during the same time period. Primary outcomes were overall cost for length of stay, operating time, and supplies. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system, and contains hospital-based data only. Secondary outcomes were 30-day rates of complications, reoperations, and readmissions.

RESULTS

We found no difference in primary or secondary outcomes following R-RYGB and L-RYGB. The overall cost for R-RYGB and L-RYGB was not statistically different (median total cost for R-RYGB and L-RYBG was $6431.34 and $6349.09, P > 0.05, respectively). Operating time cost was significantly higher for R-RYGB compared with L-RYGB ($2248.51 versus $19,836.29, respectively, P < 0.0001, respectively). R-RYGB had lower cost of supplies as well as a shorter length of stay compared with L-RYGB (mean 1.5 versus 1.7 days, respectively).

CONCLUSIONS

Our study revealed no cost difference between R-RYGB and L-RYGB, with a decreased cost of supplies and trend toward lower hospital stay favoring R-RYGB. Further studies are needed to evaluate the outcomes of R-RYGB compared with L-RYGB; however, the cost of robotic surgery may not be a prohibitive factor.

Thirty-Day Outcomes of Bariatric Surgery in Adolescents: a First Look at the MBSAQIP Database

INTRODUCTION

Bariatric surgery is the only effective treatment of severe obesity. The number of adolescents undergoing bariatric surgery is increasing. However, bariatric surgery in adolescents is controversial.

OBJECTIVE

The purpose of this study is to evaluate the outcomes of bariatric surgery in adolescents based on the MBSAQIP database (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project).

METHODS

We analyzed the 2015-2017 MBSAQIP database; patients ≤ 19 years of age were included in our analysis. Primary outcomes were 30-day serious adverse events (SAEs), organ space infection (OSI), re-intervention, and re-operation rates. Secondary outcomes included operation length, hospital stay, and re-admission rates. We conducted separate Mann-Whitney rank sums tests, chi-square, or Fisher's exact tests as appropriate, with p < .05 denoting statistical significance.

RESULTS

A total of 1983 adolescent patients were included in our analysis. The average age and BMI were 18.1 and 47.5, respectively. Of adolescent patients, 21.7% underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) and 78.3% underwent laparoscopic sleeve gastrectomy (LSG). The 30-day SAE and readmission rates were significantly lower for LSG compared with LRYGB (2.9% and 2.6% vs 6.5% and 5.6%, respectively; p < 0.05). The 30-day reoperation rate was also lower for LSG compared with LRYGB albeit not significant (1.1% and vs 2.3%; p = 0.05). The 30-day intervention rate for LSG was significantly lower, however, compared with LRYGB (1.2% vs 3%; p < 0.05). Compared with adult patients, > 19 years old (n = 353,726), we found no difference in our outcomes. However, adolescents had significantly shorter operation length.

CONCLUSION

In adolescents, LSG had fewer SAE, re-intervention, and readmission rates compared with LRYGB. There was no difference in outcomes between adolescents and adults.

Outcomes of robotic bariatric surgery in super-obese patients: first report based on MBSAQIP database

BACKGROUND

Bariatric surgery in the super-obese (SO) patient population represents a challenge. Although the robotic platform is increasingly used for these patients, there are limited data on outcomes compared with conventional laparoscopy.

OBJECTIVE

Our study compared the safety and short-term outcomes of robotic and laparoscopic platforms for SO patients compared with morbidly obese patients based on the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

SETTING

University Hospital, United States.

METHODS

We evaluated all primary robotic and laparoscopic cases and extracted 30-day outcomes in patients with body mass index <50 and ≤50 kg/m². For our primary analysis, we used the Cochran-Mantel-Haenszel method with surgery type Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG) as the stratification variable to determine the association between body mass index categories and outcomes.

RESULTS

A total of 355,278 patients were included in our analysis. For the robotic RYGB (R-RYGB) group (n = 6645) and R-SG (n = 15,984) there were 1674 SO patients (25.2%) and 3688 SO patients (23.1%), respectively.For the laparoscopic RYGB (LRYGB) group (n = 95,374) and LSG group (n = 237,275), there were 24,991 (26.2%) and 51,524 SO patients (21.7%), respectively. The incidence of serious adverse events in SO patients for R-RYGB and LRYGB groups was 7.6% versus 7.2% (P > .05) and 4% versus 3.5% (P > .05) for R-SG and L-SG, respectively. The incidence of organ space infection in SO patients for R-RYGB and LRYGB groups was .5% versus .4% (P > .05) and .4% versus .2% (P < .05) for R-SG and LSG, respectively.

CONCLUSIONS

Based on 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data, we found no difference in outcomes between robotic and laparoscopic approaches in SO patients. There was a higher incidence of serious adverse events in SO patients compared with morbidly obese patients for both approaches.

30-Day Outcomes of Revisional Bariatric Stapling Procedures: First Report Based on MBSAQIP Data Registry

INTRODUCTION

The number of bariatric revisional cases has nearly doubled since 2011, and now comprises 13.6% of the total number of cases. The objective of this study is to evaluate the outcomes and safety of the two most common stapling revisional procedures, namely, sleeve and gastric bypass in comparison to primary stapling procedures using the MBSAQIP data registry.

METHODS

We reviewed all the sleeve and gastric bypass cases entered between January 1, 2015, and December 31, 2015, in the MBSAQIP data registry. We, then, identified sleeve and bypass patients who have had a previous bariatric procedure. Demographics and 30 day outcomes of all sleeve and gastric bypass patients were analyzed. We conducted within group comparisons comparing primary sleeve gastrectomy (PS) and primary gastric bypass (PB) patients to revisional sleeve (RS) and revisional gastric bypass (RB) patients, respectively. We, then, conducted group comparisons comparing RS to RB patients.

RESULTS

The total number of patients analyzed was 141,577 (98,292 or 69% sleeve patients and 43,285 or 31% gastric bypass patients). Among the sleeve patients, 92,666 (94%) had a PS and 5626 (6%) had RS. Among the bypass patients, 39,567 (91%) had a PB and 3718 patients (9%) had RB. 30-day readmission rate of RS was significantly higher as compared to PS (4.1 vs 0.4%, p < 0.05). The incidence of at least one complication requiring reoperation or reintervention within 30 days following RS was twice as high as compared to PS (1.9 and 2% for RS vs 0.9 and 1.1% for PS respectively, p < 0.05). Length of stay and 30 day mortality rates for PS and RS were the same. 30-day readmission rate of RB as compared to PB was 8.3 vs 6.3% (p < 0.05). Also, the incidence of at least one complication requiring reoperation or reintervention following RB was 3.9 and 4%, respectively vs 2.4 and 2.7% for PB (p < 0.05). In addition, readmission rates and unplanned admission rates to the ICU were significantly higher for RB compared to RS (8.3 and 2% for RB vs 4.1 and 0.9% for RS respectively, p < 0.05). The incidence of at least one reoperation or one intervention following RB were also significantly higher compared to RS (3.9 vs 1.9% and 4 vs 2% respectively, p < 0.05).

CONCLUSION

Revisional stapling procedures are safe but the rates of complications following RS and RB are twice as high compared to PS and PB. Also, RB are more likely to develop complications compared to RS.

Robotic gastric bypass is getting better: first results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program

BACKGROUND

The use of robotic platforms in performing laparoscopic Roux-en-Y gastric bypass (LRYGB) is increasing, though their safety compared with the conventional laparoscopic approach remains unclear.

OBJECTIVE

The objective of this study was to evaluate perioperative data and 30-day outcomes of conventional and robot-assisted LRYGB using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.

SETTING

University health network, United States.

METHODS

We reviewed all conventional and robot-assisted LRYGB cases entered between January 1 and December 31, 2016 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Demographic characteristics and 30-day outcomes were analyzed based on separate Mann-Whitney rank sums tests, χ², or Fisher's exact tests as appropriate, with P ≤ .05 denoting statistical significance with no adjustment for multiple testing.

RESULTS

Of the 39,425 patients who underwent LRYGB, 2822 were robot-assisted. The robot-assisted approach required significantly more time (138 versus 108 min, P < .0001). Rates of organ space infection, bleeding, and other significant adverse events after the conventional and robot-assisted approaches were .3% versus .5% (P = .13), 1.1% versus .8% (P = .11), and 2.3% versus 2.3% (P = .96), respectively. There were also no significant differences in the rates of mortality, length of stay, reoperation, or readmission between the 2 groups.

CONCLUSIONS

Robot-assisted LRYGB is an increasingly popular alternative to the conventional laparoscopic approach. According to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, the early safety of these 2 techniques is equal, although the robotic approach requires more operative time.

Progression to surgery: online versus live seminar

OBJECTIVE

The objective of this study was to evaluate progression to surgery rates for live and online seminar and assess weight loss outcome comparisons at 1-year postoperation.

SETTING

University Hospital Network, Allentown, PA, USA.

METHODS

The entry point into our program was an information seminar where prospective patients are educated about obesity, bariatric surgery, indications and contraindications, risks and benefits, and our center's process. Between January of 2009 and November of 2011, only live information seminars were offered. In November of 2011, we started offering an online information seminar to reach those who are unable to attend a live seminar. Tracking of live versus online seminar attendance was documented in our database.

RESULTS

Between November 1, 2011 and September 30, 2015, 3484 people completed an information seminar. Of those, 2744 attendees came to a live seminar while 740 completed the online seminar. A significantly higher number of live seminar attendees, 78.1% (2144/2744) progressed to an office visit compared with online seminar attendees 66.5% (492/740), P<.0001. Similarly significant, 40.1% (1101/2744) of live seminar attendees progressed to surgery versus 29.7% (220/740) of online attendees (P<.0001). Sex (78.2% female for live seminar versus 79.5% female for online seminar, P = .65) and initial body mass index (46.3 ± 7.4 for live seminar versus 45.3 ± 7.1 for online seminar, P = .09) were very similar between the groups. Online seminar attendees' age (42.7 ± 12.1) was younger than that of the live seminar attendees' (47.3 ± 12.3) (P<.0001) but has little clinical value.

CONCLUSION

Our results demonstrated that live seminar attendees are more likely to progress to surgery and therefore should continue to be offered.

Indications for Revisions Following 630 Consecutive Laparoscopic Sleeve Gastrectomy Cases: Experience in a Single Accredited Center

INTRODUCTION

Bariatric surgery is the only proven and effective long-term treatment for morbid obesity, with laparoscopic sleeve gastrectomy (LSG) being the most commonly performed weight loss procedure in the USA. Despite its safety and efficacy, LSG's association with both de novo and pre-existing gastroesophageal reflux disease (GERD) remains controversial.

METHODS

Therefore, this retrospective study determined the incidence, indications, and outcomes of revisional surgery following LSG in adult patients at our institution from 2010 to 2014. Descriptive outcomes are reported due to the small sample size.

RESULTS

Of the 630 LSGs performed, 481 patients were included in the analysis (mean age and BMI = 46.2 and 44.3, respectively; 79.5 % female; 82.3 % white). A total of 12/481 patients underwent conversion to a different bariatric procedure due to inadequate weight loss, GERD, or both. The 6/12 patients with GERD-related symptoms and failed medical management underwent conversion to Roux-en-Y gastric bypass (RYBG) following preoperative wireless Bravo pH monitoring (Given Imaging) to confirm the diagnosis objectively. The other 6/12 patients with inadequate weight loss received either RYBG or bilio-pancreatic diversion with duodenal switch (BPD/DS) based on personal choice. Overall, 9/12 patients underwent conversion to RYBG, and 3/12 underwent conversion to BPD/DS. Median time from the initial surgery to conversion was 27 months (range 17-41). Median operating room time was 168 min (range 130-268). Median length of stay was 48 h (range 24-72). The follow-up rate at 3 months was 100 % (12/12 patients).

CONCLUSIONS

Our study showed that some patients may present following LSG with refractory GERD or inadequate weight loss, but that conversion to RYBG or BPD/DS may be done safely and effectively.

Short-Term Results of Laparoscopic Sleeve Gastrectomy in Combination with Hiatal Hernia Repair: Experience in a Single Accredited Center

BACKGROUND

Laparoscopic sleeve gastrectomy (SG), while generally safe and efficacious, may be complicated by gastroesophageal reflux disease (GERD) symptoms as well as the need for hiatus hernia (HH) repair. Identification and management of HH during SG and the effect of HH repair on GERD-related symptoms following SG are controversial.

OBJECTIVE

This study aimed to evaluate HH repair during SG in morbidly obese patients and its short-term effect on GERD-related symptoms and other clinical outcomes.

SETTING

University Hospital, United States

METHODS

We retrospectively reviewed patients who underwent primary SG and HH repair. Outcomes included operative time, blood loss, postoperative excess weight loss (%EWL), and self-reported GERD symptoms using a health-related quality of life (HRQL) questionnaire.

RESULTS

For a total of 338 patients, 99 patients (29 %) underwent SG in combination with HH repair; 56 patients (16 %) underwent anterior repair of HH (SG + HH), and 43 patients (13 %) underwent posterior repair with or without mesh placement (SG + paraesophageal hernia (PEH)). We found no significant differences in operative time or blood loss, with significantly higher %EWL at 6 months in SG + HH (n = 43) and SG + PEH (n = 32) compared to SG alone (n = 190). There was also a statistically significant improvement in postoperative GERD symptoms. Finally, SG + HH and SG + PEH patients reported greater satisfaction compared to SG patients (>93 versus 87 %).

CONCLUSIONS

SG patients undergoing HH repair experienced higher %EWL, improved GERD symptoms, and greater satisfaction compared to SG alone in the short term. Further studies are needed to clarify long-term outcomes among patients undergoing SG in combination with HH repair.

IV Acetaminophen Results in Lower Hospital Costs and Emergency Room Visits Following Bariatric Surgery: a Double-Blind, Prospective, Randomized Trial in a Single Accredited Bariatric Center

BACKGROUND

Postoperative pain control in bariatric surgery is challenging, despite use of intravenous (IV) narcotics. IV acetaminophen is one pain control alternative.

OBJECTIVE

The aim of this study was to investigate the economic impact of IV acetaminophen in bariatric surgery and its effect on patients' pain, satisfaction, and hospital length of stay.

METHODS

In a randomized controlled trial, Group 1 (treatment) received IV acetaminophen plus IV narcotics 30 min before surgery, then medication plus IV narcotics/PO narcotics for the remaining 18 h. Group 2 (control) received IV normal saline plus IV/PO narcotics. Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (SG). Primary outcomes included direct hospital costs, length of stay, postoperative pain, and patient satisfaction. Secondary outcomes included indirect costs, rescue narcotics dosage, and 30-day outcomes.

RESULTS

Mean direct hospital cost in the treatment group (n = 50) was $3089.18 versus $2991.62 for the control group (n = 50) (p > 0.05). Pain scores did not differ significantly (p = 0.61). After adjusting for surgery type, there was no significant difference in length of stay (p = 0.95). Significantly more control group patients incurred surgery-related indirect costs (10 versus 2%, p < 0.05), with greater presentation to the emergency department (ED) for abdominal pain (5/50 versus 1/50), yielding higher total indirect costs ($39,293 versus $13,185).

CONCLUSIONS

Using IV acetaminophen for postoperative pain management produced notable indirect cost savings and reduced ED visits in the first 30 days postoperatively, with good safety and tolerance. Decreased statistical power may have accounted for certain non-significant findings.

Laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass: a single center experience with 2 years follow-up

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) is a relatively new procedure that is gaining wide acceptance. However, laparoscopic Roux-en-Y Gastric Bypass (LRYGB) remains one of the most commonly performed bariatric procedures with the best long-term results. There are few studies comparing LSG with LRYGB. The aim of this study is to compare the safety and outcome of LSG to LRYG in a single accredited center.

METHODS

A retrospective analysis of data collected prospectively on patients undergoing either LSG or LRYGB between January 2009 and December 2012 was performed. LSG was performed using 36Fr bougie, while LRYGB was perfromed with a 25-mm circular stapler. The primary outcomes included length of stay (LOS), 30-day complication and readmission rates, and excess weight loss (%EWL) at 3, 6, 12, and 24 months postoperatively. LSG patients were also divided into different categories based on BMI and their %EWL compared to LRYGB.

RESULTS

A total of 885 patients were included in our analysis. 547 patients underwent LRYGB (61.8 %) and 338 underwent LSG (38.2 %). Thirty-day complication and readmission rates for LRYGB and LSG were (1.5 and 5.1 % vs 0.6 and 0.3 %, respetively, p > 0.05). %EWL for LRYGB was significantly higher than LSG at 3, 6, 12, and 24 months. LSG with a BMI <40 achieved a similar %EWL to LRYGB in the first 12 months.

CONCLUSIONS

LSG seems to have a better safety profile in the short-term compared to LRYGB. However, at 2 years, LRYGB patients achieved a significantly higher EWL compared to LSG patients. Randomized clinical trials are needed to better elucidate our findings.

Improving outcome of bariatric surgery: best practices in an accredited surgical center

The number of laparoscopic bariatric procedures being performed in the USA has increased dramatically in the past decade. Because of limited health-care resources, hospital administrators and insurance carriers are placing emphasis on length of stay and patient outcomes. The goal of this study was to evaluate the feasibility and safety of a clinical pathway in managing patients undergoing bariatric surgery in a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited center. The setting was a university hospital in USA. A retrospective analysis of data collected prospectively on patients undergoing bariatric surgery at St Luke's University was performed. Patients included underwent either a laparoscopic Roux-en-Y gastric Bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). Patients were subjected to a clinical protocol and discharged when discharge criteria were met. The primary outcomes were length of stay, 30 day readmission, complication, and reoperation rates. A cost analysis of the savings accrued was also performed. Two hundred twenty-nine patients were included in our analysis (80.4% females and 19.6% males). Seventy-one patients (31%) underwent LSG, and 158 patients (69%) underwent LRYGB. The average length of stay was 32.45 h (range 24-72 h). The 30-day readmission rate was 3.0% (7/229 patients). The 30 day complication rate (including intervention, reintubation, and reoperation) was 2.6% (6/229). The 30 day mortality rate was 0. The average prospective cost savings were $2,016 and $1,209 per LRYGB and LSG patient, respectively. Our bariatric surgery clinical protocol is feasible and safe with substantial prospective cost savings at St Luke's University and Health Network. Patients subjected to our protocol have low readmission and complication rates. Further studies are needed to fully elucidate the benefit of this innovative new protocol in bariatric surgery.

Docosahexaenoic acid selectively augments muscarinic stimulation of epithelial Cl- secretion

BACKGROUND

We investigated the effect of various fatty acids on electrogenic chloride secretion in T84 cells, a model for intestinal epithelium.

MATERIALS AND METHODS

T84 intestinal epithelial cells grown on permeable supports were studied by conventional current-voltage clamping. Membrane lipids from T84 cells were extracted, transmethylated, and analyzed by gas chromatography. Lipid extracts were fractionated into nonpolar, free fatty acids, and phospholipids by amynopropil column chromatography.

RESULTS

Docosahexaenoic acid (DHA) but not eicosapentanoic acid or other fatty acids selectively enhanced the secretory response to the muscarinic agonist carbachol but not the response to other Ca2+ agonists (histamine, thapsigargin, or ionomycin) or the response to the cAMP agonist forskolin. The ability of DHA to augment Cl- secretion appeared to correlate closer with free DHA levels than with membrane-bound DHA. Other effects of DHA on T84 cells included a reduction in transepithelial resistance (a measure of barrier function), actions that were dissociated from the effect on Cl- secretion.

CONCLUSION

The results suggest that DHA, which has been shown to reverse organ pathology in experimental cystic fibrosis, may selectively affect agonist-regulated transport events and other fundamental properties of epithelial cells.