Sustained culture and surgical outcome improvement.

BACKGROUND: A focus on the culture of safety and patient outcomes continues to grow in importance. Several initiatives targeted at individual deficits have been described but few institutions have shown the effect of a global change in culture on patient outcomes. METHODS: Patient care perception was assessed using Safety Attitudes Questionnaire (SAQ) by Pascal Metrics®. A change in culture was initiated, followed by implementation of initiatives targeting communication and patient safety. ACS-NSQIP data was analyzed to assess outcomes during the period of improved culture. RESULTS: Our institution had poor outcomes as measured by ACS-NSQIP data and several deficiencies in our culture score. Both statistically improved after initiative implementation. A difference in mean culture score across time (p < 0.001 = .031) was seen from 2013 to 2015, while NSQIP odds ratios falling in the 'exemplary' category increased. CONCLUSION: Our results demonstrate an improvement in both culture and outcomes from 2013 to 2015, suggesting a correlation between culture and surgical outcomes.

Total laparoscopic removal of accessory gallbladder: A case report and review of literature.

Accessory gallbladder is a rare congenital anomaly occurring in 1 in 4000 births, that is not associated with any specific symptoms. Usually this cannot be diagnosed on ultrasonography and hence they are usually not diagnosed preoperatively. Removal of the accessory gallbladder is necessary to avoid recurrence of symptoms. H-type accessory gallbladder is a rare anomaly. Once identified intra-operatively during laparoscopic cholecystectomy, the surgery is usually converted to open. By using the main gallbladder for liver traction and doing a dome down technique for the accessory gallbladder, we were able to perform the double cholecystectomy with intra-operative cholangiogram laparoscopically. Laparoscopic cholecystectomy was performed in 27-year-old male for biliary colic. Prior imaging with computer tomography-scan and ultrasound did not show a duplicated gallbladder. Intraoperatively after ligation of cystic artery and duct an additional structure was seen on its medial aspect. Intraoperative cholangiogram confirmed the patency of intra-hepatic and extra-hepatic biliary ducts. Subsequent dissection around this structure revealed a second gallbladder with cystic duct (H-type). Pathological analysis confirmed the presence of two gallbladders with features of chronic cholecystitis. It is important to use cholangiogram to identify structural anomalies and avoid complications.

Is the use of prosthetic mesh recommended in severely obese patients undergoing concomitant abdominal wall hernia repair and sleeve gastrectomy?

BACKGROUND: The concomitant use of nonabsorbable mesh during stapled bariatric surgery has been discouraged due to potential contamination. The aim of our study was to compare and quantify the extent of bacterial load and gross contamination of the peritoneal cavity in patients undergoing laparoscopic sleeve gastrectomy (LSG) vs those undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). STUDY DESIGN: We prospectively enrolled all patients undergoing LSG and LRYGB. Peritoneal fluid aspirate samples were collected from each subject. Sample A was obtained at the beginning of the procedure, and sample B was obtained at the end of the procedure either from the staple line wash of the LSG or the gastrojejunostomy in the LRYGB. RESULTS: A total of 77 patients (51 LSG and 26 LRYGB) and 154 samples (102 from LSG and 52 from LRYGB) were included in this study. All samples obtained at the beginning of each procedure (sample A) were culture negative. Samples of peritoneal fluid obtained at the end of the procedure (sample B) in sleeve gastrectomy procedures were all negative (0%) after a minimum of 72 hours for aerobic and anaerobic cultures. Those obtained for LRYGB (sample B) were culture positive in 4 of 26 (15%). The latter results are statistically significant (p < 0.05). CONCLUSIONS: Intraperitoneal bacterial cultures in patients undergoing LSG are negative, contrary to those in patients undergoing LRYGB. The concomitant use of prosthetic material to repair ventral hernias in patients undergoing an LSG procedure should be safe and feasible.

Mid-term results of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in adolescent patients.

The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m2. The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months follow-up was 188.4 lbs and average BMI was 30.1 kg/m2. Fifteen of the patients were available for follow-up. Thirteen out of 16 (81%) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.

Procedure-related morbidity in bariatric surgery: a retrospective short- and mid-term follow-up of a single institution of the American College of Surgeons Bariatric Surgery Centers of Excellence.

BACKGROUND: Our objective was to ascertain procedure-related morbidity among laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB) patients. These are the 3 most common bariatric procedures performed worldwide. We reviewed our experience since the introduction of LSG and compared the procedure-related morbidity among all 3 procedures. STUDY DESIGN: We conducted a retrospective review of a prospectively collected database of all morbidly obese patients who underwent bariatric surgery between the years 2005 and 2011. We identified and compared complications, mortality, readmissions, and reoperations in patients who underwent LRYGB, LAGB, and LSG. RESULTS: A total of 2,199 bariatric procedures were performed during this period of time. Of those procedures, 1,327 were LRYGB, 619 were LSG, and 253 were LAGB. Perioperative mortality was not applicable for all 3 procedures. The leak rate was 0.5% for LRYGB and 0.3% for LSG, and was not applicable for LAGB. The average number of readmissions postoperatively was less than 2 times for all 3 procedures: LRYGB 1.96 times, LSG 1.49 times, and LAGB 1.54 times. The percentages of procedures requiring reoperations due to complications or failures were 14.6% in the LAGB group, 6.6% in the LRYGB group, and 1.8% in the LSG group. CONCLUSIONS: In short- and mid-term follow-up, LSG appears to have the lowest procedure-related morbidity when compared with LRYGB and LAGB.