Same-day discharge on laparoscopic Roux-en-Y gastric bypass patients: an outcomes review.

INTRODUCTION: The objective of this research was to study safety and outcomes in patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) on an ambulatory outpatient basis. As the prevalence of morbid obesity increases, more patients are opting for surgical weight loss as a means to combat their chronic disease. There are several studies demonstrating the safety and feasibility of select patients undergoing LRYGB on a 23-h outpatient basis, but few studies exist regarding the safety and efficacy of these procedures being performed on an ambulatory outpatient basis. METHODS: A retrospective review was completed on all patients who underwent a laparoscopic gastric bypass procedure from 2008 to 2018 at a single outpatient ambulatory surgery center. Median BMI was 46.7 kg/m2. Inclusion criteria included age > 18 and < 65, ASA class less than 3, completion of a bariatric surgery preparation program, no history of major cardiovascular events, and no prior major open abdominal operations. Exclusion criteria included males > 55 years, BMI > 55 for men, and BMI > 60 for women. Operations included primary LRYGB procedures. We determined 30-day post-operative morbidity and mortality for all patients. RESULTS: There were 398 patients who underwent a LRYGB on an ambulatory basis. After thorough chart review, a total of 362 patients were included. The majority were women (315, 87%). The median age was 42 (range 19-65). Seven (1.93%) patients were directly admitted to the hospital, while 13 (3.59%) patients were admitted to the hospital after initial discharge. There were 3 (0.83%) leaks, 4 (1.11%) bleeds requiring transfusion, no wound infections, 1 (0.28%) obstruction, one (0.28%) venous thrombotic event and/or pulmonary embolism, and 9 (2.49%) reoperations. There were zero deaths. CONCLUSIONS: This study demonstrates that laparoscopic Roux-en-Y gastric bypass is both feasible and safe when performed on select patients on an ambulatory outpatient basis.

Does the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a safe and effective procedure that can be performed as an outpatient procedure. OBJECTIVES: The aim of the study was to determine whether same-day discharge LSG is safe when performed in an outpatient surgery center. SETTING: Outpatient surgery centers. METHODS: The medical records of 3162 patients who underwent primary LSG procedure by 21 surgeons at 9 outpatient surgery centers from January 2010 through February 2018 were retrospectively reviewed. RESULTS: Three thousand one hundred sixty-two patients were managed with enhanced recovery after surgery protocol and were included in this analysis. The mean age and preoperative body mass index were 43.1 ± 10.8 years and 42.1 ± 7.1 kg/m2, respectively. Sleep apnea, type 2 diabetes, gastroesophageal reflux disease, hypertension, and hyperlipidemia were seen in 14.4%, 13.5%, 24.7%, 30.4%, and 17.6% patients, respectively. The mean total operative time was 56.4 ± 16.9 minutes (skin to skin). One intraoperative complication (.03%) occurred. The hospital transfer rate was .2%. The 30-day follow-up rate was 85%. The postoperative outcomes were analyzed based on the available data. The 30-day readmission, reoperation, reintervention, and emergency room visit rates were .6%, .6%, .2%, and .1%, respectively. The 30-day mortality rate was 0%. The total short-term complication rate was 2.5%. CONCLUSIONS: Same-day discharge seems to be safe when performed in an outpatient surgery center in selected patients. It would appear that outpatient surgery centers are a viable option for patients with minimal surgical risks.

Transaxillary endoscopic thyroidectomy: an alternative to traditional open thyroidectomy.

BACKGROUND: The traditional thyroidectomy technique typically approaches the thyroid through a range of different sized transverse incisions in the neck. Such a scar can result in hypesthesias, paresthesias, and increased patient self-awareness. Furthermore, in some patients of darker-skin ethnicity, the traditional neck incision can result in hyperplastic and keloid scar formation in a highly visible area of the neck. In an effort to lessen this adverse cosmetic outcome, we recently began performing endoscopic thyroidectomy, as described by Ikeda et al, using an axillary approach to conceal the incisions. We recently reviewed our series and studied the feasibility and safety of this approach in patients undergoing thyroidectomy. We herein present our results in the use of this procedure in all patients requiring thyroid resection and highlight the potential advantage in patients having a tendency for hypertrophic cervical scarring. From August 2003 to January 2008 we performed a transaxillary endoscopic thyroidectomy on 53 patients. Forty-one patients were of African descent. All patients underwent successful completion of thyroidectomy using this approach. CONCLUSIONS: Excellent aesthetic results with no visible scarring in the neck region can be safely achieved with this innovative surgical technique. Although the procedure has been shown to be of benefit to all patients, an added advantage may be seen in those patients prone to hypertrophic scarring. Transaxillary endoscopic thyroidectomy is a safe alternative to the traditional open approach in select patients with benign thyroid disease.

Endoscopic total thyroidectomy.

BACKGROUND AND OBJECTIVE: Endoscopic neck surgery for the thyroid and parathyroid is being tested as an alternative to open thyroidectomy. The aim of this study was to determine the safety and feasibility of endoscopic transaxillary total thyroidectomy (ETTT). METHODS AND RESULTS: Twenty-two consecutive patients from January 2006 to September 2008 underwent ETTT. No conversions to open were necessary. Mean age was 49.3+/-12.9 years, 20 were female, and 2 were male. Mean operating time was 238 minutes+/-72.7. Mean blood loss was 40mL+/-28.3mL. Mean weight of the gland was 137.05g+/-129.21g. The recurrent laryngeal nerve was identified with no permanent injury. Six patients developed hoarseness of the voice for a mean of 15.1+/-8.01 days. No patient developed tetany or hypocalcemia requiring treatment. Six patients experienced transient numbness in the anterior chest wall lasting 2 weeks in 5 patients and 2 months in one. All patients were discharged within 24 hours of admission. CONCLUSION: ETTT requires additional operative time compared with the open approach, but is cosmetically favorable. Visualization of the nerve and parathyroid is much better. Although the learning curve is steep, with experience the operative time will decrease. ETTT is different but safe and feasible.

Surgical excision of large multinodular goiter using an endoscopic transaxillary approach: a case report.

BACKGROUND: Minimal access surgery for thyroid and parathyroid disease has gained increasing popularity due to excellent endoscopic visualization and overall cosmetic outcome. Most current techniques limit the size of the gland that can be removed to less than 4 cm. Patients with multinodular goiter with gland size greater than 4 cm commonly present for surgical therapy. We evaluated the use of an endoscopic transaxillary approach for the treatment of large multinodular goiters. We herein present a case report of 3 consecutive patients undergoing this technique for benign multinodular goiter disease. METHODS: Three consecutive patients with large multinodular goiter (>6 cm) were treated using a transaxillary endoscopic approach. RESULTS: All patients had successful endoscopic thyroidectomy using a transaxillary endoscopic approach. There were no recurrent nerve injuries. One patient had transient hypoparathyroidism that subsequently resolved after surgery. CONCLUSIONS: Transaxillary endoscopic thyroidectomy may be a viable option to open cervical thyroidectomy in the treatment of patients with large multinodular goiter. We herein present a case report of 3 consecutive patients undergoing this technique for benign multinodular goiter disease.

Endoscopic transaxillary near total thyroidectomy.

BACKGROUND: Since first reported in 1996, endoscopic minimally invasive surgery of the cervical region has been shown to be safe and effective in the treatment of benign thyroid and parathyroid disease. The endoscopic transaxillary technique uses a remote lateral approach to the thyroid gland. Because of the perceived difficulty in accessing the contralateral anatomy of the thyroid gland, this technique has typically been reserved for patients with unilateral disease. OBJECTIVES: The present study examines the safety and feasibility of the transaxillary technique in dissecting and assessment of both thyroid lobes in performing near total thyroidectomy. METHODS: Prior to this study we successfully performed endoscopic transaxillary thyroid lobectomy in 32 patients between August 2003 and August 2005. Technical feasibility in performing total thyroidectomy using this approach was accomplished first utilizing a porcine model followed by three human cadaver models prior to proceeding to human surgery. After IRB approval three female patients with histories of enlarging multinodular goiter were selected to undergo endoscopic near total thyroidectomy. RESULTS: The average operative time for all models was 142 minutes (range 57-327 min). The three patients in this study had clinically enlarging multinodular goiters with an average size of 4 cm. The contralateral recurrent laryngeal nerve and parathyroid glands were identified in all cases. There was no post-operative bleeding, hoarseness or subcutaneous emphysema. CONCLUSION: Endoscopic transaxillary near total thyroidectomy is feasible and can be performed safely in human patients with bilateral thyroid disease.

Consequences of conversion in laparoscopic colorectal surgery.

INTRODUCTION: Laparoscopic procedures converted to open approaches have been associated with higher complication rates than laparoscopic and open cholecystectomy and appendectomy. Laparoscopic colorectal resections have relatively high conversion rates compared with other laparoscopic procedures. This study was designed to evaluate outcomes of conversions compared with laparoscopic and open colorectal resections. METHODS: We reviewed 498 consecutive colorectal resections performed between 1995 and 2002. Procedures were divided into laparoscopic colorectal resections, open colorectal resections, or conversions. Demographics, underlying disease, type of procedure performed, and operative outcomes were compared between groups. RESULTS: Of the 238 laparoscopic procedures performed, 182 were completed laparoscopically and 56 (23 percent) required conversion; 260 were performed open. Conversions were associated with greater blood loss (200 (range, 50-750) vs. 100 (range, 30-900) ml), longer time to first bowel movement (82 (range, 40-504) vs. 72 (range, 12-420) hr), and longer length of stay (6 (range, 2-67) vs.. 5 (range, 2-62) days) than the laparoscopic colorectal resections group. There was no difference in operative time, transfusion requirements, intraoperative and postoperative complications, or mortality between conversions and laparoscopic colorectal resections. Conversions resulted in fewer patients requiring transfusions (4 vs. 14 percent), shorter time to first bowel movement (82 (range, 40-504) vs. 93 (range, 24-240) hr), and shorter length of stay (6 (range, 2-67) vs. 7 (range, 2-180) days) than in the open colorectal resections group. There were no differences in complications or mortality between the conversion group and the open colorectal resections group. CONCLUSIONS: Laparoscopic colorectal resections has a relatively high conversion rate; however, the converted cases have outcomes similar to open colorectal resections. In fact, the converted group required fewer blood transfusions than the open group. Experience and good judgment are fundamental for timely conversion of a laparoscopic procedure to open to decrease complication rates. Despite a high conversion rate, surgeons should consider laparoscopic colorectal resections, because even when necessary, conversion does not result in poorer outcomes than laparoscopic colorectal resections or open colorectal resections.

Laparoscopic versus open umbilical hernia repair.

BACKGROUND: The use of prosthetic material for open umbilical hernia repair has been reported to reduce recurrence rates. The aim of this study was to compare outcomes after laparoscopic versus open umbilical hernia repair. METHODS: We reviewed all umbilical hernia repairs performed from November 1995 to October 2000. Demographic data, hernia characteristics, and outcomes were compared. RESULTS: Of the 76 patients identified, 32 underwent laparoscopic repair (LR), 24 primary suture repairs (PSR), and 20 open repairs with mesh (ORWM). Preoperative characteristics were similar between groups. Hernia size was similar between LR and ORWM groups, and both were larger than that in the PSR group. ORWM compared with the other techniques resulted in longer operating time, more frequent use of drains, higher complication rates, and prolonged return to normal activities (RTNA). The length of stay (LOS) was longer in the ORWM than in the PSR group. When compared with ORWM, LR resulted in lower recurrence rates. LR resulted in fewer recurrences in patients with previous repairs and hernias larger than 3 cm than in both open techniques. CONCLUSIONS: LR results in faster RTNA, and lower complication and recurrence rates compared with those in ORWM. Patients with larger hernias and previous repairs benefit from LR.