Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial.

BACKGROUND: Use of liposomal bupivacaine (LB) in surgery is reported with decreased postoperative opioid requirements. The efficacy of LB versus standard bupivacaine injections at laparoscopic port sites during bariatric surgery is unknown. OBJECTIVES: To determine whether there was a difference in postoperative hospital opioid requirements after port site injections of LB versus standard bupivacaine during laparoscopic bariatric surgeries. Primary endpoint was total in hospital opioid use expressed as morphine-equivalent use. Secondary endpoints included home opioid use, pain scores, hospital length of stay, and adverse events. SETTING: Academic-affiliated private practice. METHODS: A 2-group randomized, double-blinded trial from November 2017 to August 2018 with patients randomly assigned to receive either LB or bupivacaine alone at trocar site injections during laparoscopic Roux-en-Y gastric bypass (LRYGB) or vertical sleeve gastrectomy (VSG). All patients underwent enhanced recovery after bariatric surgery protocols. RESULTS: All patients undergoing LRYGB or VSG assessed for eligibility. Of 682 patients undergoing LRYGB or VSG, 231 met inclusion criteria, 52 patients excluded intraoperatively. Among 231 patients (mean age, 39.2 years; 79% women; mean body mass index 45.0), 179 patients (77%) completed the trial. Patients randomly assigned to receive either LB (n = 89) or bupivacaine alone (n = 90) at trocar site injection during LRYGB or VSG. Postoperative morphine-equivalent use were similar (LB 8.3 [standard deviation 4.0-13.9] versus bupivacaine group 7.5 [standard deviation 3.6-13.1] P = .94) with highest requirement in first 4 hours after surgery. There was no significant difference in length of stay, pain scores, or complications. There were more patients in the bupivacaine group that did not take pain medications on postoperative days 2 to 4 (P = .032, P = .23, P = .005, respectively). There were more patients in the bupivacaine group 48.1% (n = 39) compared with the LB group 34.2% (n = 27) that did not consume any narcotic tablets at home but this not found to be statistically significant (P value = .07). CONCLUSIONS: Among patients undergoing primary bariatric surgery under enhanced recovery after bariatric surgery protocol, there was no significant difference in postoperative hospital opioid use in those receiving LB compared with standard bupivacaine. A greater percentage of patients in the standard bupivacaine group did not require any narcotics at home, which was significant on postoperative days 2 to 4. To become completely opioid free after bariatric surgery, resources should be focused on multimodal approaches instead of reliance on type of anesthetic medication used.

Traditional autopsy versus computed tomography imaging autopsy in trauma: A case of "synergistic disagreement".

BACKGROUND: Decreases in the rates of traditional autopsy (TA) negatively impact traumatology, especially in the areas of quality improvement and medical education. To help enhance the understanding of trauma-related mortality, a number of initiatives in imaging autopsy (IA) were conceived, including the postmortem computed tomography ("CATopsy") project at our institution. Though IA is a promising concept, few studies directly correlate TA and IA findings quantitatively. Here, we set out to increase our understanding of the similarities and differences between key findings on TA and IA in a prospective fashion with blinding of pathologist and radiologist evaluations. METHODS: A prospective study of TA versus IA was conducted at an Academic Level I Trauma Center (June 2001-May 2010). All decedents underwent a postmortem, whole-body, noncontrast computed tomography that was interpreted by an independent, blinded, board-certified radiologist. A blinded, board-certified pathologist then performed a TA. Autopsy results were grouped into predefined categories of pathologic findings. Categorized findings from TA and IA were compared by determining the degree of agreement (kappa). The χ(2) test was used to detect quantitative differences in "potentially fatal" findings (eg, aortic trauma, splenic injury, intracranial bleeding, etc) between TA and IA. RESULTS: Twenty-five trauma victims (19 blunt; 9 female; median age 33 years) had a total of 435 unique findings on either IA or TA grouped into 34 categories. The agreement between IA and TA was worse than what chance would predict (kappa = -0.58). The greatest agreement was seen in injuries involving axial skeleton and intracranial/cranio-facial trauma. Most discrepancies were seen in soft tissue, ectopic air, and "incidental" categories. Findings determined to be "potentially fatal" were seen on both TA/IA in 48/435 (11%) instances with 79 (18%) on TA only and 53 (12%) on IA only. TA identified more "potentially fatal" solid organ and heart/great vessel injuries, while IA revealed more spine injuries, "potentially fatal" procedure-related findings, and the presence of ectopic air/fluid. CONCLUSION: This limited study does not support substitution of noncontrast, computed tomography-based IA for TA. Our quantitative analyses suggest that TA and IA evaluations may be complementary and synergistic when performed concurrently. There are potential benefits to using IA in trauma process/quality improvement and in educational settings. Further research should focus on the value (and limitations) of the information provided by IA in the absence of TA.

Management of Excessive Weight Loss Following Laparoscopic Roux-en-Y Gastric Bypass: Clinical Algorithm and Surgical Techniques.

BACKGROUND: There are no clinical guidelines or published studies addressing excessive weight loss and protein calorie malnutrition following a standard Roux-en-Y gastric bypass (RYGB) to guide nutritional management and treatment strategies. This study demonstrates the presentation, clinical algorithm, surgical technique, and outcomes of patients afflicted and successfully treated with excessive weight loss following a standard RYGB. METHODS: Three patients were successfully reversed to normal anatomy after evaluation, management, and treatment by multidisciplinary team. Lowest BMI (kg/m(2)) was 18.9, 17.9, and 14.2, respectively. RESULTS: Twelve-month post-operative BMI (kg/m(2)) was 28.9, 22.8, and 26.1, respectively. Lowest weight (lbs) was 117, 128, and 79, respectively. Twelve-month post-operative weight (lbs) was 179, 161, and 145, respectively. Pre-reversal gastrostomy tube was inserted into the remnant stomach to demonstrate weight gain and improve nutritional status prior to reversal to original anatomy. CONCLUSION: We propose a practical clinical algorithm for the work-up and management of patients with excessive weight loss and protein calorie malnutrition after standard RYGB including reversal to normal anatomy.