A Prospective Multicenter Standard of Care Study of Outpatient Laparoscopic Sleeve Gastrectomy.

A global shift is occurring as hospital procedures move to ambulatory surgical settings. Surgeons have performed outpatient sleeve gastrectomy (SG) in bariatric surgery since 2010. However, prospective trials are needed to ensure its safety before widespread adoption. PURPOSE: The study aimed to present a comprehensive report on the prospective data collection of 30-day outcomes of outpatient primary laparoscopic SG (LSG). This trial seeks to assess whether outpatient LSG is non-inferior to hospital-based surgery in selected patients who meet the outpatient surgery criteria set by the American Society for Metabolic and Bariatric Surgery. MATERIALS AND METHODS: This study is funded by the Society of American Gastrointestinal and Endoscopic Surgeons and has been approved by the Advarra Institutional Review Board (Pro00055990). Cognizant of the necessity for a prospective approach, data collection commenced after patients underwent primary LSG procedures, spanning from August 2021 to September 2022, at six medical centers across the USA. Data centralization was facilitated through ArborMetrix. Each center has its own enhanced recovery protocols, and no attempt was made to standardize the protocols. RESULTS: The analysis included 365 patients with a mean preoperative BMI of 43.7 ± 5.7 kg/m2. Rates for 30-day complications, reoperations, readmissions, emergency department visits, and urgent care visits were low: 1.6%, .5%, .2%, .2%, and 0%, respectively. Two patients (0.5%) experienced grade IIIb complications. There were no mortalities or leaks reported. CONCLUSION: The prospective cohort study suggests that same-day discharge following LSG seems safe in highly selected patients at experienced US centers.

Single-incision laparoscopic cholecystectomy at community hospitals in Honolulu, Hawai'i: a case series.

This study aims to demonstrate the feasibility of implementing single-incision laparoscopic cholecystectomy in a community hospital setting. Minimally invasive surgical approaches for cholecystectomy achieve equivalent outcomes to the open surgical approach with less post-operative pain, improved cosmesis, shorter hospital stays, and decreased complications. Surgeons are attempting to reduce incisional trauma further by decreasing the number of incisions. A retrospective chart review was conducted for demographics, operating time, blood loss, conversion rate, length of stay, and presence of operative complications on patients undergoing single-incision laparoscopic cholecystectomy at two community hospitals between 2008 and 2011. One hundred and three patients (79 females and 24 males) underwent single-incision laparoscopic cholecystectomy. The mean age was 49.8 years (range 18-88). Ninety-six patients (93.2%) underwent elective procedures while 7 patients (6.8%) underwent urgent procedures. The mean operating time was 89.7 (± 28.3) minutes and the average blood loss was 33.7 (± 27.4) milliliters. Ninety-five (92.2%) of the procedures were successfully completed with a single-incision approach and 8 (7.8%) were converted to a multi-incisional approach, while none were converted to an open approach. The median length of stay was 4.75 hours. The post-operative complication rate was 7.4% (7/95) and included four superficial wound infections, one bile leak, one acute renal failure, and one urinary tract infection. These outcomes for single-incision laparoscopic cholecystectomy are comparable to other case series reported in the literature, and this retrospective review illustrates that single-incision laparoscopic cholecystectomy is feasible in a community setting.

Prescription drug cost reduction in Native Hawaiians after laparoscopic Roux-en-y gastric bypass.

OBJECTIVE: Native Hawaiians (NH) represent a unique population where socioeconomic factors have contributed to higher incidence rates of obesity and related comorbidities than in the general population resulting in substantial prescription medication costs. Studies demonstrate that laparoscopic Roux-en-y gastric bypass (LRYGB) surgery results in significant weight loss, improvement of comorbidities, and decreased costs for prescription medications in Caucasians. This study aimed to analyze the effects of LRYGB surgery on Native Hawaiians and their prescription drug costs. METHODS: Demographics, baseline body mass index (BMI), comorbidities, preoperative, and postoperative data were analyzed for NH patients who underwent LRYGB between January 2004 and April 2009. Medication costs were determined using the online pharmacy . Generic drugs were selected when appropriate, while vitamins and nutritional supplements were not included in this study. RESULTS: Fifty (14 Men, 36 women) NH patients had sufficient data and follow-up for analysis. Average preoperative BMI was 49 kg/m(2), while at one year follow-up it decreased to 33 kg/m(2) (P<.001). This correlates to an average of 61% excess body weight lost (P<.001). The average number of prescription medications decreased from 3.5/patient preoperatively to 1.1/patient at one year (P<.001), equating to a monthly cost savings of US $195.8/patient (P<.001). CONCLUSIONS: LRYGB provided substantial weight loss for morbidly obese NH patients, resulting in significantly less prescription medication use and substantial cost savings. Thus, bariatric surgery for weight management has the potential to improve the overall well-being and lower the financial burden of medical care in socioeconomically disadvantaged communities such as the NH.

Novel technique for preoperative localization of colorectal tumors for laparoscopic resection.

Minimally invasive surgery for resection of colon tumors is being utilized with increasing frequency making accurate preoperative tumor localization essential to proper surgical planning and patient positioning. Traditional endoscopic localization techniques such as lesion distancing from the anal verge are adequate in the majority of patients. Patients with a significantly tortuous and redundant colon, however, are at increased risk for ambiguous and incorrect lesion localization. The use of endoscopic submucosal marking by injection to tattoo the site of interest may increase the accuracy of tumor localization, but its efficacy can be technique dependent. We present a novel technique for endoscopic tumor localization using endoscopic clip placement, followed by immediate abdominal radiograph, to accurately locate a colonic lesion in preparation for laparoscopic colonic resection.

Robotic-assisted Roux-en-Y gastric bypass performed in a community hospital setting: the future of bariatric surgery?

INTRODUCTION: Since receiving Food and Drug Administration approval in 2000, surgery utilizing a robot has been successfully performed in numerous procedures including gastric bypass. However, despite the proven safety profile, reported lower complication rates, and technical benefits of robotic surgery, only a few centers in the USA have consistently applied this technology to bariatric surgery. In addition, there are limited studies with relatively small sample sizes comparing robotic-assisted Roux-en-Y gastric bypass (RRYGB) with laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: Through a retrospective analysis of our database, we compared outcomes of RRYGB versus LRYGB in the treatment of morbid obesity. All patients who underwent RRYGB and LRYGB through the Comprehensive Weight Management Program of the Queen's Medical Center (Honolulu, HI) from January 2007 to December 2009 were included. Outcomes data included weight loss, operative times, and hospital length of stay. All complications were reported. RESULTS: 105 patients who underwent RRYGB were compared with 195 patients who received LRYGB. Excess weight loss, estimated blood loss, and length of hospital stay were similar in both groups. There were no mortalities in either group. The RRYGB group experienced a 9.5% complication rate versus 9.7% in LRYGB patients. Operative time was the only statistically significant difference, being approximately 17 min in favor of LRYGB. However, there was a steady decrease in RRYGB operative time with increasing experience. CONCLUSION: Our study demonstrates a favorable safety profile with nearly equivalent outcomes and some previously unidentified qualitative benefits of the RRYGB approach to bariatric surgery in a community setting. These results are despite our early experience with the robotic surgery platform and confirm noninferiority of RRYGB versus LRYGB. While the RRYGB operative time was longer than LRYGB, the demonstrated decrease in operative time commensurate with increase in operative experience holds tremendous promise for the future.

Band erosion: laparoscopic removal of lap-band.

Laparoscopic gastric banding is in the category of purely restrictive gastric procedures. It offers the advantage of being minimally invasive, adjustable, and reversible. The incidence of band erosion with penetration into stomach is well documented in literature. We present a case of band erosion and simultaneous laparoscopic removal of lap-band through the same incisions used for its placement. The stomach was repaired with laparoscopic suture placement and an omental patch was placed on top of the repair along with fibrin glue and a JP drain. An upper gastrointestinal study demonstrated no extravasation of contrast and the patient was discharged postoperative day 1.

Intestinal interposition for benign esophageal disease.

OPINION STATEMENT: Various options exist for intestinal interposition for benign, but debilitating, end-stage esophageal disorders. Principally, the stomach, colon, or jejunum is used for esophageal replacement. Much debate exists regarding the ideal esophageal replacement option. The conduit choice must be tailored to the individual patient. Unlike malignant processes, the conduit choice for benign disorders must be sufficiently durable and functional. Colonic interposition meets both criteria. However, this operative procedure's technical difficulty increases the complexity of this already challenging clinical problem, as seemingly small errors in judgment and technique can significantly impact graft viability and long-term function. Using a gastric tube also provides durability and functionality, but with an operative procedure that is less technically demanding. A minimally invasive laparoscopic transhiatal esophagectomy offers the patient even more benefit in terms of shorter operative times and intensive care unit and recovery periods. However, the advent of surgical robotic technology augments these benefits even further. Robotic technology arms the surgeon with improved dexterity and three-dimensional visualization. These revolutionary improvements allow the surgeon to overcome many of the operative limitations that exist with the open and minimally invasive approaches to esophagectomy, thus potentially offering patients reduced morbidity and mortality rates.

Long-term follow-up outcome of patients undergoing radiofrequency ablation for unresectable hepatocellular carcinoma.

The long-term outcome of radiofrequency thermal ablation (RFA) for unresectable hepatocellular carcinoma (HCC) has not been reported. This study was performed to evaluate the long-term survival of patients with unresectable HCC after RFA and to identify possible factors that might affect survival. In this prospective study, 65 patients with unresectable HCC who underwent RFA were followed. A total of 84 RFA operations were performed percutaneously (n = 49), laparoscopically (n = 20), or by open surgery (n = 15), to ablate 191 tumors. Twenty-two patients died within 16 months; otherwise, the follow-up period was at least 16 months, up to 71 months, with median 20.0 months and mean (+/- standard deviation) 24.8 +/- 18.4 months for all patients. Local tumor recurrence developed in 12 of 191 tumors (6.3%) in 11 of 84 operations (13.1%), or 11 of 65 patients (16.9%). New liver and/or extrahepatic recurrence developed in 48 operations (57.1%). The overall median, mean, and 5-year survivals were 40.0 months, 33.7 +/- 2.9 months, and 39.9%. The disease-free survivals were 16.0 month, 32.9 +/- 3.0 months, and 27.9%. Factors that had a significant effect on survival outcome after RFA were TNM cancer stage and the operative approach method employed for RFA. Age, gender, race, etiology, alpha-fetoprotein, previous or subsequent treatment, and liver function (Child-Pugh class) did not affect survival. For patients with unresectable HCC, RFA is an effective and repeatable local treatment that can afford long-term survival, although often with disease recurrence.

Impact of the number of negative nodes on disease-free survival in colorectal cancer patients.

PURPOSE: Between 1995 and 1999, we observed an increasing number of nodes being recovered from colorectal specimens. Patients with colorectal cancer were studied to determine whether increasing the number of negative nodes recovered would better stage the patient and more accurately predict disease-free survival. METHODS: All patients undergoing colorectal resection with curative intent between 1995 and 1999 at a tertiary referral hospital were retrospectively reviewed. Tumor stage, grade, number of nodes recovered, and the association of these factors with disease-free survival was analyzed. RESULTS: Three hundred forty-five patients with M0 disease undergoing surgical resection of carcinoma of the colon or rectum were studied. There was no statistically significant difference in tumor stage or grade during the study period. A statistically significant increase in the mean number of nodes recovered was observed during the study period. Node-positive patients did substantially worse than node-negative individuals. When compared with a national cancer registry (OncoPool), we observed a significantly greater number of nodes sampled in our study population and a statistically significant improved disease-free survival between our node-negative patients and that of the national cancer registry population. CONCLUSION: The extent of the pathologic assessment of the nodal status of colorectal cancer patients as determined by the number of nodes examined affects disease-free survival. The need for quality control for uniform pathologic assessments is critical.

Laparoscopic donor nephrectomy in Hawaii.

Laparoscopic donor nephrectomy for transplant is a minimally invasive, effective, and safe operation that also provides less post-operative pain and earlier return to pre-donation activity. In review of the first 10 cases, no major complications occurred and mean hospital stay was 3.7 days. All recipients of these kidneys displayed excellent allograft function (mean creatinine--1.5 mg/dL) and no ureteral problems. Successful use of this procedure has also resulted in a steady increase in the number of living transplants performed in Hawaii and perhaps this will impact the 330 patients currently awaiting renal transplant.